Authorization to Release Confidential Information

Sarah Moreau, Arctic Vision, LLC Owner

5372 E. Hart Lake Loop, Wasilla, AK 99654

Phone: 907-707-5564 arcticvision2020@gmail.com
Authorization for Exchange of Confidential Information
Name Of Child/Client*

First NameLast Name
Child/Client Birthdate:*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
As the parent or legal guardian of the above named child, I hereby grant my permission to:
Name of person you are granting permission (ex. Teacher or orientation and mobility specialist name)*

First NameLast Name
School/Company *
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
To exchange confidential information concerning my child with:

Arctic Vision, LLC

5372 E. Hart Lake Loop

Wasilla, AK 99654

907-707-5564
The purpose of this authorization is:*
i.e. Educational Programming, consult with Arctic Vision, LLC
I understand that my permission covers the release of permanent and temporary records, as well as the release of confidential records and reports. I understand that I provide permission for verbal communication for educational purpose, and/or consultation regards.
Signature of Parent/Guardian/or Adult Student over 18 years*

Clear
Date:*

MonthDayYear
Phone Number*

Area CodePhone Number
Signature of Student (Age 12 17, if applicable)*

Clear
Date*

MonthDayYear
Date this authorization expires (1 year from submission):*

MonthDayYear
Should be Empty:

Authorization for Exchange of Confidential Information