Authorization for Release of Information

  I authorize any of the following individuals to share and exchange information about my child with CAPE Head Start and for CAPE Head Start to share and exchange information about my child with these individuals or agencies. Any information received or shared will be used to evaluate and coordinate services for my child. I understand that this information is confidential and protected by federal law. I approve the release of this information and understand what this agreement means.



Use the fields below for other physicians, organizations, or individuals