Release of Information – Special Needs Support Center

Name*
First Last
I give permission for the staff and volunteers of SNSC to share and exchange information with the staff of the organizations listed below for the purpose of providing assistance to me or my child.*
- Yes
- No
You may exchange information with the following organizations:*
The information may be exchanged in the following ways:
- By Email
- By Mail
- In Person
- By Phone
Yes,*
- I understand the purpose of this form and understand its content. This box indicates my consent.
Yes,*
- I understand that my personal information may be shared with team members at Special Needs Support Center if necessary.
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