CHILD RELEASE OF INFORMATION

CHILD RELEASE OF INFORMATION
I hereby authorize:
Agency Name*
Contact's Name (therapist, clinician, psychologist, teacher, etc.)*
Address*

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Email*
example@example.com
Phone number & extension*
Fax Number (if applicable)*
to release information to Big Brothers Big Sisters of San Diego County and receive information from Big Brothers Big Sisters of San Diego County on child listed below.

To: Big Brothers Big Sisters of San Diego County 4305 University Ave. Suite 590 San Diego, CA 92105

Statement of Purpose/Need for Information: The above named child has applied to be a Little Brother/Sister and to be matched with an adult mentor. Information is being requested in order to assist the Enrollment & Matching Specialist in selecting a mentor for this child and for the purpose of goal setting and supervision of the match relationship. The agency may also need information on the child’s physical, behavioral, and/or emotional functioning; peer relationships; self concept and well being; school performance; family interaction; and overall appropriateness for the mentoring program. If the above named agency referred the child and family to Big Brothers Big Sisters of San Diego County, information may also be released to the referring agency on the status of the match for this child.
Name of Child*
Signature of Parent/Guardian*

Clear
Date*

MonthDayYear
Date
This request will be valid only for the length of the child’s participation in the Big Brothers Big Sisters of San Diego County program.
Should be Empty: