Early Childhood Programs Toronto Page 7

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CONSENT FOR THE RELEASE OF INFORMATION
I/we ______________________________________________________________________
Print name of Parent or Legal Guardian (First Name, Last Name)
of _______________________________________________________________________
Address of Parent or Legal Guardian
Hereby consent to the release of the following information:
(Check only those that apply)
q Attendance
q
q Psychological
Psychiatric
q Physiotherapy
q Occupational Therapy
q Medical
q Developmental
q Speech-Language
q Social Work
q Other:__________________________________________________________________
Compiled/prepared by:________________________________________________________
Name of School/Child Care/Family Support/Agency/Individual
In respect to: _______________________________
___________________________
Name of Child
Date of Birth (DD/MM/YY)
To: _______________________________________________________________________
Name of School/Child Care/Family Support/Agency/Individual
q Educational Planning
q Service Planning
For the purposes of:
q Service Coordination
q Service Provision
q Other:_____________________________________________
Special Instructions/Restrictions:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
_______________________________ *
________________________________
Signature of Parent/Guardian
Date (DD/MM/YY)
_______________________________
________________________________
Witness
Date (DD/MM/YY)
This consent to release information form remains valid until ___________________________
Date (DD/MM/YY)
* Authorizing person(s) may cancel or change the above authorization in writing at any time prior to the expiry date, unless action has
already been taken on the basis of the authorization.
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