Birth to Three -Release of Information

Birth to Three -Release of Information
Child's Name #1

First NameLast Name
Child's Name #2

First NameLast Name
Child's Name #3

First NameLast Name
Date of birth #1

MonthDayYear
Date
Date of birth #2

MonthDayYear
Date
Date of birth #3

MonthDayYear
Date
As a parent/guardian of the child name above, I hereby grant

Muckleshoot Indian Tribe Head Start ProgramMuckleshoot Indian Tribe CCDF ProgramMuckleshoot Indian Tribe Birth to Three Program/Support ServicesMuckleshoot Indian Tribe Child Development Center
To request information relevant to my child/family from:

Muckleshoot Indian Tribe Health/Wellness Center 17500 SE 392nd St Auburn,WAMuckleshoot Indian Tribe Enrollment DepartmentMuckleshoot Casino, Human ResourcesMuckleshoot Bingo Hall Human ResourcesMuckleshoot Indian Tribe Finance DepartmentMary Bridge Pediatrics: 202 N Division St #300 Auburn, wa 98002Auburn Health Point: 126 Auburn Ave, Auburn WA 98002Other
Including any or all of the following (as checked below):

Child Health information (well-child exam, Dental exam, Immunizations, Lead/Hemoglobin/Hematocrit test results)Family eligibility information, including current family status or employment/income verificationChild's Birth CertificateChild's Tribal StatusChild Development/educational information (assessments/progress reports)Information regarding child's special needs (observations, individual education plan) if applicableFamily Services information (needs assessment, service plan)Other (please specify)Other
I understand that the confidentiality of any information identifying my child and/or myself will be maintained in accordance with the law and both federal and state regulations. Such information will only be used with my consent for the benefit of my child or me.

By signing below, I also acknowledge that:

I may review the indicated information at any time

This is authorization is voluntary, and I may refuse to sign it. My refusal to sign will not affect my eligibility for services or enrollment.

This authorization will expire one (1) year from the date below, but I may also choose to revoke it at any time.
Parent/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty: