Summit County Juvenile Court
School/Medical Provider Request
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Case Number (if known)
Name of Requestor
*
First Name
Last Name
Email of Requestor
*
example@example.com
Phone Number of Requestor
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
School or Medical Provider?
School
Medical Provider
Name of School District
Reason for Request
Name of Medical Provider/Facility
Reason for Request
File Upload
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Use this to upload release forms from parent/guardian only
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