Missouri DeafBlind Project (Project) at the Missouri School for the Blind
Release of Information Form

I understand that the Project offers a variety of services and benefits. Each agency must have specific information in order to provide these services and benefits and protect the student's information.

The Missouri DeafBlind Census includes information on the number of individuals (ages birth through 21 years of age) with deafblindness along with the types of services these individuals and their families receive. This information is used to determine the needs of infants, children, and youth identified with deafblindness within a given area.

Additionally, the United States Office of Special Education Programs (OSEP) provides funding to the Missouri DeafBlind Technical Assistance Project based on the identified needs and number of infants, children, and youth identified with deafblindness in Missouri. Therefore, it is important that all individuals with deafblindness are included in this Census to to ensure appropriate and effective planning for their future. Personal Identifiable Information (PII) is NOT reported to OSEP.

The parties agree that this agreement may be electronically signed. Furthermore, the parties agree that the electronic signatures represent the same validity, enforceability, and admissibility as handwritten signatures.

If you prefer to opt-out of the electronic version and would rather sign an agreement manually, go to the Missouri DeafBlind Project website and download the Parent Guardian Release of Information form. Please fill it out and return it to Robert Blachowicz, DeafBlind Project Coordinator: robert.blachowicz@msb.dese.mo.gov

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* 1. Full name of the child.

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* 2. I understand the following:
  • The purposes of the exchanged information as described in the text above.
  • I have the right to inspect and receive a copy of the information to be shared.
  • I am providing my consent voluntarily, and I understand the information on this form.
  • I have a right to revoke this release at any time.
  • If I revoke this release, I must do so in writing and present my written revocation to Outreach Services, Missouri School for the Blind, 3815 Magnolia Ave, St. Louis, MO 63110.
  • Actions already taken based on this release, prior to revocation, will not be affected.
  • The release of information will remain in effect for one year — unless I specify an expiration date in the comments of this form.
By clicking "I agree," you agree to the statements written above.

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* 3. Enter parent/guardian contact information.

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* 4. By typing my name below, I give my informed consent and give permission for my child’s name and pertinent data to be kept on the Missouri DeafBlind Census for planning programs for all deafblind infants, children, and youth. This permission will remain in effect as long as the student is registered in this district, until a written revocation is provided by the parent/guardian, or until the student reaches his or her age of majority.

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* 5. Comments? (Expiration date may be included here.)

Missouri DeafBlind Project Contact Information:
Missouri School for the Blind
3815 Magnolia Avenue
St. Louis, MO 63110
Contact Robert Blachowicz, DeafBlind Project Coordinator
314-633-1587
robert.blachowicz@msb.dese.mo.gov

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