DOB:Date*      
Patient Address:Street Address*         City*   
State*   Zip*   
Phone 1:  Number*           Phone 2:   Number      
Email 1:   Email*   Email 2:   Email   

School / Organization: Name*
Contact name:   First Name   Last Name   
Address:   Street Address*      City*   State*   Zip*   
Phone: Phone Number* Fax:   Fax*   
Email:   Email   

I hereby voluntarily authorize:
- The INDIVIDUAL OR AGENCY (above) and the entirety of their faculty and staff
AND
- ON TARGET PEDIATRIC THERAPY at 2012 HAROBI DRIVE, SUITE A, TUCKER, GA 30084 (PHONE: (770) 892-6878/FAX: (404) 521-4121) and the entirety of their faculty and staff....
.....to communicate with, exchange and/or disclose (release) any and all confidential information and/or records of my child (above patient).

Person signing & authorizing release of patient’s records/information (please check one):  
 Parent   Legal Guardian   Patient/Self  Other *     Specify   
  
Parent/Guardian Printed Name & Signature:

First Name*   Last Name*      Parent/Guardian Signature*   Date*