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Authorization For Release Of Information

Authorization for Release of Information

I._______________________________________________________give Permission for

(Parent or legal guardian)

(Profession/facility)

To release to___________________________________the following information

(Child Care program)

(Screenings, test, diagnoses, and treatment, or recommendations)

The information will be used to plan and coordinate the care of my child and will be kept confidential and

may only be shared with_________________________________________________________________

(Staff title/name)

Name of

Child:_________________________________________________________________________________

Address:_____________________________________________________________________________

City: ________________________________State______Zip Code:_____________________________

Date of Birth: ________________________________________________________

Parent/Legal Guardian Signature

Date

______________________________________________________________________________________

Witness Signature

Date

Staff member to be contacted for additional information

Resource: Model Child Care Health Policies, 4

Edition

Authorization For Release Of Information