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Get FL FM-2128E - Miami-Dade County 2020

my child or myself, ___________ _____________________________ , between the MIAMI-DADE COUNTY PUBLIC SCHOOLS and the following agencies (include all schools, physicians, psychologists, hospitals, clinics, etc., that have had significant contact with your child): Name Address z The specific records to be disclosed pertain to: z The purpose for making these records available is: z The receiving party will not disclose the information to any other party without signed consent. I certify tha.

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