- Snohomish County Early Childhood Education and Assistance Program
Authorization to Release Confidential Information
Revised July 2009
Child’s Name (First, Middle, Last) Date of Birth
Please list any identifier(s) to assist in locating records i.e.
- Medical Identification/Record No.
- This authorization is voluntary and I may refuse to sign this authorization to release information which will not affect my child’s ability
to participate in ECEAP.
- Person(s)
And/or Organization
Street Address
City, State, Zip
Phone No.
- _______ I give my permission to release the records if it contains protected information relating only to:
P...
Release of info- print on YELLOW -health, mh, edu.... 
