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Authorization for the Release of Information

I/We, the parent(s)/guardian(s) of the child noted above, consent to the collection of information by, and the release of information to, an authorized representative of the City of Cornwall’s Child Care Division.   We also consent to the release and receipt of observation, assessment, and behaviour information for the purposes of planning service delivery in respect of the child between an authorized representative of the City of Cornwall’s Child Care Division and the following people or agencies checked below:

Please be advised that you will receive copies of all reports, resources and recommendations that are provided to the child care centre by the Child Care Advisor(s).

This form is valid from the date of signing to the closure of service.  I/We fully understand the nature and purpose of this consent and have given my consent and authorization voluntarily.

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