Release of Information Form

  • Permission for the Release of Information

    The purpose of this form is to give us permission to receive information from other professionals who work with your student. This allows us to better know your student during the application process and helps us determine whether or not our Summer Program will be a good match for him/her. In addition, should your student attend one of our programs, we will have the opportunity to communicate with those who know your student best throughout the summer. We will also be happy to share information about your student's experience with these same professionals once they have finished the program.
  • (Physician, Psychiatrist, Therapist or other Clinician)
  • (Physician, Psychiatrist, Therapist or other Clinician)
  • (Physician, Psychiatrist, Therapist or other Clinician)
  • ACKNOWLEGEMENT

  • I understand that this information will be kept confidential and will not be released to any agencies or parties not listed above without further consent.
  • Please type your full name below
  • Please type your email address.
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