Childcare Assistance Records Release Form

Childcare Assistance Records Release Form
Please complete this form to authorize the release of childcare assistance records.
Full Name of Parent/Guardian
First NameLast Name
Child's Full Name
First NameLast Name
Date of Birth of Child
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Records to be Released
Specify Other Records (if applicable)
Reason for Release
Authorization Signature
Clear
Date of Authorization
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: