School/Medical Provider Request

Summit County Juvenile Court

School/Medical Provider Request
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Case Number (if known)
Name of Requestor*

First NameLast Name
Email of Requestor*
example@example.com
Phone Number of Requestor*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
School or Medical Provider?

SchoolMedical Provider
Name of School District
Reason for Request
Name of Medical Provider/Facility
Reason for Request
File Upload

Use this to upload release forms from parent/guardian only
Cancelof
Should be Empty:

Summit County Juvenile Court