Parental Consent to Release Minor’s Information
Minor's Full Name
Date of Birth
Parent/Legal Guardian Name
Relationship to Minor
Contact Number
Email Address
Recipient of Information (Name/Organization)
Purpose of Disclosure
Type of Information to be Released
I authorize the release of my child’s information as described above.
I understand that this consent is voluntary and may be revoked at any time in writing.
Parent/Guardian Signature
Date