Permission For The Release of Information Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.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 *FirstLastCamper BirthdatePROFESSIONAL 1 (Teacher/School Professional) *FirstLastProfessional Title *Length of Relationship *Email *Phone *United States +1United States+1United Kingdom+44Afghanistan+93Albania+355Algeria+213American Samoa+1Andorra+376Angola+244Anguilla+1Antigua & Barbuda+1Argentina+54Armenia+374Aruba+297Ascension Island+247Australia+61Austria+43Azerbaijan+994Bahamas+1Bahrain+973Bangladesh+880Barbados+1Belarus+375Belgium+32Belize+501Benin+229Bermuda+1Bhutan+975Bolivia+591Bosnia & Herzegovina+387Botswana+267Brazil+55British Indian Ocean Territory+246British Virgin Islands+1Brunei+673Bulgaria+359Burkina Faso+226Burundi+257Cambodia+855Cameroon+237Canada+1Cape Verde+238Caribbean Netherlands+599Cayman Islands+1Central African Republic+236Chad+235Chile+56China+86Christmas Island+61Cocos (Keeling) Islands+61Colombia+57Comoros+269Congo - Brazzaville+242Congo - Kinshasa+243Cook Islands+682Costa Rica+506Croatia+385Cuba+53Curaçao+599Cyprus+357Czechia+420Côte d’Ivoire+225Denmark+45Djibouti+253Dominica+1Dominican Republic+1Ecuador+593Egypt+20El Salvador+503Equatorial Guinea+240Eritrea+291Estonia+372Eswatini+268Ethiopia+251Falkland Islands+500Faroe Islands+298Fiji+679Finland+358France+33French Guiana+594French Polynesia+689Gabon+241Gambia+220Georgia+995Germany+49Ghana+233Gibraltar+350Greece+30Greenland+299Grenada+1Guadeloupe+590Guam+1Guatemala+502Guernsey+44Guinea+224Guinea-Bissau+245Guyana+592Haiti+509Honduras+504Hong Kong SAR China+852Hungary+36Iceland+354India+91Indonesia+62Iran+98Iraq+964Ireland+353Isle of Man+44Israel+972Italy+39Jamaica+1Japan+81Jersey+44Jordan+962Kazakhstan+7Kenya+254Kiribati+686Kosovo+383Kuwait+965Kyrgyzstan+996Laos+856Latvia+371Lebanon+961Lesotho+266Liberia+231Libya+218Liechtenstein+423Lithuania+370Luxembourg+352Macao SAR China+853Madagascar+261Malawi+265Malaysia+60Maldives+960Mali+223Malta+356Marshall Islands+692Martinique+596Mauritania+222Mauritius+230Mayotte+262Mexico+52Micronesia+691Moldova+373Monaco+377Mongolia+976Montenegro+382Montserrat+1Morocco+212Mozambique+258Myanmar (Burma)+95Namibia+264Nauru+674Nepal+977Netherlands+31New Caledonia+687New Zealand+64Nicaragua+505Niger+227Nigeria+234Niue+683Norfolk Island+672North Korea+850North Macedonia+389Northern Mariana Islands+1Norway+47Oman+968Pakistan+92Palau+680Palestinian Territories+970Panama+507Papua New Guinea+675Paraguay+595Peru+51Philippines+63Poland+48Portugal+351Puerto Rico+1Qatar+974Romania+40Russia+7Rwanda+250Réunion+262Samoa+685San Marino+378Saudi Arabia+966Senegal+221Serbia+381Seychelles+248Sierra Leone+232Singapore+65Sint Maarten+1Slovakia+421Slovenia+386Solomon Islands+677Somalia+252South Africa+27South Korea+82South Sudan+211Spain+34Sri Lanka+94St. Barthélemy+590St. Helena+290St. Kitts & Nevis+1St. Lucia+1St. Martin+590St. Pierre & Miquelon+508St. Vincent & Grenadines+1Sudan+249Suriname+597Svalbard & Jan Mayen+47Sweden+46Switzerland+41Syria+963São Tomé & Príncipe+239Taiwan+886Tajikistan+992Tanzania+255Thailand+66Timor-Leste+670Togo+228Tokelau+690Tonga+676Trinidad & Tobago+1Tunisia+216Turkey+90Turkmenistan+993Turks & Caicos Islands+1Tuvalu+688U.S. Virgin Islands+1Uganda+256Ukraine+380United Arab Emirates+971United Kingdom+44United States+1Uruguay+598Uzbekistan+998Vanuatu+678Vatican City+39Venezuela+58Vietnam+84Wallis & Futuna+681Western Sahara+212Yemen+967Zambia+260Zimbabwe+263Åland Islands+358AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePROFESSIONAL 2 *FirstLastProfessional Title *Length of Relationship * Email *Phone *United States +1United States+1United Kingdom+44Afghanistan+93Albania+355Algeria+213American Samoa+1Andorra+376Angola+244Anguilla+1Antigua & Barbuda+1Argentina+54Armenia+374Aruba+297Ascension Island+247Australia+61Austria+43Azerbaijan+994Bahamas+1Bahrain+973Bangladesh+880Barbados+1Belarus+375Belgium+32Belize+501Benin+229Bermuda+1Bhutan+975Bolivia+591Bosnia & Herzegovina+387Botswana+267Brazil+55British Indian Ocean Territory+246British Virgin Islands+1Brunei+673Bulgaria+359Burkina Faso+226Burundi+257Cambodia+855Cameroon+237Canada+1Cape Verde+238Caribbean Netherlands+599Cayman Islands+1Central African Republic+236Chad+235Chile+56China+86Christmas Island+61Cocos (Keeling) Islands+61Colombia+57Comoros+269Congo - Brazzaville+242Congo - Kinshasa+243Cook Islands+682Costa Rica+506Croatia+385Cuba+53Curaçao+599Cyprus+357Czechia+420Côte d’Ivoire+225Denmark+45Djibouti+253Dominica+1Dominican Republic+1Ecuador+593Egypt+20El Salvador+503Equatorial Guinea+240Eritrea+291Estonia+372Eswatini+268Ethiopia+251Falkland Islands+500Faroe Islands+298Fiji+679Finland+358France+33French Guiana+594French Polynesia+689Gabon+241Gambia+220Georgia+995Germany+49Ghana+233Gibraltar+350Greece+30Greenland+299Grenada+1Guadeloupe+590Guam+1Guatemala+502Guernsey+44Guinea+224Guinea-Bissau+245Guyana+592Haiti+509Honduras+504Hong Kong SAR China+852Hungary+36Iceland+354India+91Indonesia+62Iran+98Iraq+964Ireland+353Isle of Man+44Israel+972Italy+39Jamaica+1Japan+81Jersey+44Jordan+962Kazakhstan+7Kenya+254Kiribati+686Kosovo+383Kuwait+965Kyrgyzstan+996Laos+856Latvia+371Lebanon+961Lesotho+266Liberia+231Libya+218Liechtenstein+423Lithuania+370Luxembourg+352Macao SAR China+853Madagascar+261Malawi+265Malaysia+60Maldives+960Mali+223Malta+356Marshall Islands+692Martinique+596Mauritania+222Mauritius+230Mayotte+262Mexico+52Micronesia+691Moldova+373Monaco+377Mongolia+976Montenegro+382Montserrat+1Morocco+212Mozambique+258Myanmar (Burma)+95Namibia+264Nauru+674Nepal+977Netherlands+31New Caledonia+687New Zealand+64Nicaragua+505Niger+227Nigeria+234Niue+683Norfolk Island+672North Korea+850North Macedonia+389Northern Mariana Islands+1Norway+47Oman+968Pakistan+92Palau+680Palestinian Territories+970Panama+507Papua New Guinea+675Paraguay+595Peru+51Philippines+63Poland+48Portugal+351Puerto Rico+1Qatar+974Romania+40Russia+7Rwanda+250Réunion+262Samoa+685San Marino+378Saudi Arabia+966Senegal+221Serbia+381Seychelles+248Sierra Leone+232Singapore+65Sint Maarten+1Slovakia+421Slovenia+386Solomon Islands+677Somalia+252South Africa+27South Korea+82South Sudan+211Spain+34Sri Lanka+94St. Barthélemy+590St. Helena+290St. Kitts & Nevis+1St. Lucia+1St. Martin+590St. Pierre & Miquelon+508St. Vincent & Grenadines+1Sudan+249Suriname+597Svalbard & Jan Mayen+47Sweden+46Switzerland+41Syria+963São Tomé & Príncipe+239Taiwan+886Tajikistan+992Tanzania+255Thailand+66Timor-Leste+670Togo+228Tokelau+690Tonga+676Trinidad & Tobago+1Tunisia+216Turkey+90Turkmenistan+993Turks & Caicos Islands+1Tuvalu+688U.S. Virgin Islands+1Uganda+256Ukraine+380United Arab Emirates+971United Kingdom+44United States+1Uruguay+598Uzbekistan+998Vanuatu+678Vatican City+39Venezuela+58Vietnam+84Wallis & Futuna+681Western Sahara+212Yemen+967Zambia+260Zimbabwe+263Åland Islands+358Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeProfessional 3FirstLastProfessional TitleLength of Relationship * * Relationship EmailPhoneUnited States +1United States+1United Kingdom+44Afghanistan+93Albania+355Algeria+213American Samoa+1Andorra+376Angola+244Anguilla+1Antigua & Barbuda+1Argentina+54Armenia+374Aruba+297Ascension Island+247Australia+61Austria+43Azerbaijan+994Bahamas+1Bahrain+973Bangladesh+880Barbados+1Belarus+375Belgium+32Belize+501Benin+229Bermuda+1Bhutan+975Bolivia+591Bosnia & Herzegovina+387Botswana+267Brazil+55British Indian Ocean Territory+246British Virgin Islands+1Brunei+673Bulgaria+359Burkina Faso+226Burundi+257Cambodia+855Cameroon+237Canada+1Cape Verde+238Caribbean Netherlands+599Cayman Islands+1Central African Republic+236Chad+235Chile+56China+86Christmas Island+61Cocos (Keeling) Islands+61Colombia+57Comoros+269Congo - Brazzaville+242Congo - Kinshasa+243Cook Islands+682Costa Rica+506Croatia+385Cuba+53Curaçao+599Cyprus+357Czechia+420Côte d’Ivoire+225Denmark+45Djibouti+253Dominica+1Dominican Republic+1Ecuador+593Egypt+20El Salvador+503Equatorial Guinea+240Eritrea+291Estonia+372Eswatini+268Ethiopia+251Falkland Islands+500Faroe Islands+298Fiji+679Finland+358France+33French Guiana+594French Polynesia+689Gabon+241Gambia+220Georgia+995Germany+49Ghana+233Gibraltar+350Greece+30Greenland+299Grenada+1Guadeloupe+590Guam+1Guatemala+502Guernsey+44Guinea+224Guinea-Bissau+245Guyana+592Haiti+509Honduras+504Hong Kong SAR China+852Hungary+36Iceland+354India+91Indonesia+62Iran+98Iraq+964Ireland+353Isle of Man+44Israel+972Italy+39Jamaica+1Japan+81Jersey+44Jordan+962Kazakhstan+7Kenya+254Kiribati+686Kosovo+383Kuwait+965Kyrgyzstan+996Laos+856Latvia+371Lebanon+961Lesotho+266Liberia+231Libya+218Liechtenstein+423Lithuania+370Luxembourg+352Macao SAR China+853Madagascar+261Malawi+265Malaysia+60Maldives+960Mali+223Malta+356Marshall Islands+692Martinique+596Mauritania+222Mauritius+230Mayotte+262Mexico+52Micronesia+691Moldova+373Monaco+377Mongolia+976Montenegro+382Montserrat+1Morocco+212Mozambique+258Myanmar (Burma)+95Namibia+264Nauru+674Nepal+977Netherlands+31New Caledonia+687New Zealand+64Nicaragua+505Niger+227Nigeria+234Niue+683Norfolk Island+672North Korea+850North Macedonia+389Northern Mariana Islands+1Norway+47Oman+968Pakistan+92Palau+680Palestinian Territories+970Panama+507Papua New Guinea+675Paraguay+595Peru+51Philippines+63Poland+48Portugal+351Puerto Rico+1Qatar+974Romania+40Russia+7Rwanda+250Réunion+262Samoa+685San Marino+378Saudi Arabia+966Senegal+221Serbia+381Seychelles+248Sierra Leone+232Singapore+65Sint Maarten+1Slovakia+421Slovenia+386Solomon Islands+677Somalia+252South Africa+27South Korea+82South Sudan+211Spain+34Sri Lanka+94St. Barthélemy+590St. Helena+290St. Kitts & Nevis+1St. Lucia+1St. Martin+590St. Pierre & Miquelon+508St. Vincent & Grenadines+1Sudan+249Suriname+597Svalbard & Jan Mayen+47Sweden+46Switzerland+41Syria+963São Tomé & Príncipe+239Taiwan+886Tajikistan+992Tanzania+255Thailand+66Timor-Leste+670Togo+228Tokelau+690Tonga+676Trinidad & Tobago+1Tunisia+216Turkey+90Turkmenistan+993Turks & Caicos Islands+1Tuvalu+688U.S. Virgin Islands+1Uganda+256Ukraine+380United Arab Emirates+971United Kingdom+44United States+1Uruguay+598Uzbekistan+998Vanuatu+678Vatican City+39Venezuela+58Vietnam+84Wallis & Futuna+681Western Sahara+212Yemen+967Zambia+260Zimbabwe+263Åland Islands+358AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeI 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. 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