To be filled out, printed and signed by the child's parent or guardian and the Child Care Provider, to be given to the child's physician or other medical/professional provider to authorize the release of necessary health information.

Request to:

Name of Professional:
Address of Professional:
Name of Child:
Child's Birth Date:	(mm/dd/yyyy)

I consent to the release of the most recent records concerning the above child to
. 
         (name of child care provider)

This child is enrolled at:	(name of child care program)
	(address of child care program)

Please release to me the most recent records for this child, including developmental evaluations, medical records, and program plans so that I may provide better services to this child.