Release of information - One Stop Parenting and Visitation Program LLC

One Stop Parenting and Visitation Program, LLC

Release of Information and Authorization

This will serve to notify the individual/agency named below that I grant permission for:

The individual/agency named below to share and provide any and all information, including written documentation, to the One Stop Parenting program regarding my previous supervised visitation.

Sharing of information as described below:

The individual/agency named below to share the following information to One Stop Parenting:

One Stop Parenting to share the following information to the individual/agency named below:

This authorization does not extend to any other individual/agency beyond the individual/agency named below. This authorization will expire in 12 months from the date of signing or upon case closing, whichever occurs first, unless otherwise specified below:

A copy/fax of this authorization shall be deemed as an original and shall have the same force and effect as such original. Name of individual/agency authorized to receive/send information:

Name

Address

Telephone #

Signature of Parent/Guardian/Young Adult