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Form Authorizing Information Release

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The text below can be pasted into a document, printed, and taken to a Notary Public to witness your signing it in their presence.

For your convenience, you can also download our printable PDF of the authorization form.

AUTHORIZATION FOR RELEASE OF INFORMATION

I, ____________________________________, hereby authorize ______________________________ to release information to or discuss my child ____________________________, whose date for birth is _______________________,
with ________________________________________.

Parent/Guardian Signature ________________________________________________
Date Signed ___________________________________________________________

Notary Signature _______________________________________________________
County/Parish of ________________________ State of ________________________
My Commission Expires _________________________________________________