Jeff Schwiebert Superintendent of Schools

320-656-3715 Fax 320-656-3765

Krista Durrwachter Director of Human Resources

Email: [email protected]

320-656-3748 Fax 320-656-3765

Email: [email protected]

Sartell-St. Stephen School District No. 748 Human Resources Office 212 Third Avenue N Sartell, MN 56377

AUTHORIZATION FOR RELEASE OF INFORMATION

Name__________________________________________________ Date_______________

I hereby authorize Sartell-St. Stephen School District #748 to release the following information: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

This information is to be released to: ___________________________________________________________________________ ___________________________________________________________________________

The expiration of this authorization shall be for a period no longer than one year from the date of my signature.

________________________________________________ (Signature)

___________________ (Date)

________________________________________________ (Street Address)

___________________ (Phone Number)

________________________________________________ (City) (State) (Zip Code)

“An Equal Opportunity Employer”