South Carolina Youth ChalleNGe Academy
Digital Release of Confidential Information
It is requested that any professional, legal, educational, medical or mental health information you have regarding the individual above be released to the South Carolina Youth Challenge Academy, 5471 Leesburg Road, Bldg 3892, Eastover, SC 29044.
This information includes any medical reports, psychological reports, psychiatric evaluations, psychiatric hospital records, mental health reports or summaries, school transcripts/records (to include Individual Education Plans, psychological reports , 504 plan, BIP, birth certificate, social security card, immunization records, attendance records, discipline records, etc.), legal and/or criminal history records and status, DJJ Form V, evaluations and other pertinent information which schools, counselors, medical professionals, mental health professionals/agencies, legal professionals or agencies, may have needed for review to decide on acceptance at the South Carolina Youth Challenge Academy.
I Understand my refusal to consent to the release of information specified above will prevent disclosure of such information to South Carolina Youth Challenge Academy, thereby removing my application from consideration or causing my dismissal from the program.