Authorization to Release Information

I, the undersigned, do hereby authorize the University of Arizona Speech Language and Hearing Clinics,

on behalf of The Child Language Center, to release information as stipulated below, including pictures,

audio or video tapes, to any agency or individual who is, or may be directly involved in the examination,

treatment and/or recommendations concerning my child.

Today's Date

YYYY

Clint/Patient Name:

First Name

Last Name

Date of Birth

YYYY

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Type of Info

Indicate YES or NO to permit or deny release of information. Written Information

Yes

Pictures

Yes

Audio Tapes/Digital Recordings

Yes

Video Tapes/Digital Recordings

Yes

Printed Name

Authorized by (By printing your name, you are acknowledging the printed name on this document will act as your temporary authorization and we will require you to sign the document):

First Name

Last Name

Signature

Relationship to Client/Patient

Address if Different Than Client/Patient