Parent/Guardian Release Authorization PLEASE PRINT & RETURN TO: Mr. E. Bertolini, Principal Leonia High School 100 Christie Heights Street Leonia, NJ 07605

The Leonia Academy for Science offers a rigorous academic program designed for those students who are interested in a particular area of study and are eager for the accompanying demands and special challenges. We kindly ask that you discuss issues such as increased time commitment, an increased workload, and a longer school day with your child so that you can make the best decision. The Academy Selection Committee requires certain information to make an appropriate decision regarding admission. It will not be possible to make an appropriate decision without your child's academic records, attendance records, health records, discipline records, and special education records. By signing below: 1) I authorize my son's or daughter's school district to make available academic records, attendance records, health records, discipline records, and special education records to the Leonia Science Academy. 2) I recognize that my child, if accepted, will be involved in a highly demanding academic program that will require his or her best effort and will involve a greater time commitment, an increased workload, and an extended school day.

Student Name____________________________________________________ Parent/Guardian Signature____________________ Date _________________