Permission For Release | Green Cove Day Camp

Permission For The Release of Information

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The purpose of this form is to give us permission to receive information from other professionals who work with your child. This allows us to better know your child during the application process and helps us determine whether or not Green Cove Day Camp will be a good match for them. In addition, should your child attend Green Cove, we will have the opportunity to communicate with those who know your child best throughout the summer. We will also be happy to share information about their camp experience with these same professionals once the summer is over.

IMPORTANT: Please ask the people listed below to complete the Professional Questionnaire portion of our online application on your child’s behalf. After receiving their written questionnaire, we will follow up with them as needed.

I, the undersigned, so hereby give my permission for Green Cove Day Camp and the following list of agencies or individuals to share information about my child:

Camper Name

First

Last

Camper Birthdate

PROFESSIONAL 1 (Teacher/School Professional)

First

Last

Professional Title

Length of Relationship

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

PROFESSIONAL 2

First

Last

Professional Title

Length of Relationship

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Professional 3

First

Last

Professional Title

Length of Relationship

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

1 Address Address

I understand that this information will be kept confidential by Green Cove Day Camp and will not be released to any agencies or parties not listed above without further consent.

Parent/Guardian Signature

Clear Signature

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