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Release of Information

Name of Participant(Required)

Release of Information (ROI) Consent(Required)
I understand my student’s story and/or my story is ours to share. I understand Back2Back Cincinnati will hold our information confidential unless necessary by law. I realize Back2Back Cincinnati can better serve my student and/or our family when they communicate to other individuals working with my student and/or our family. I give permission for Back2Back Cincinnati to give and receive information with the following organizations and individuals in regards to my student(s) and/or myself:
If ROI is Authorized from Schools
I give permission to release the following information to Back2Back Cincinnati:

Name of Consenting Guardian or Student (if over 18)(Required)
Submitting your name below as a digital signature, you are acknowledging any release of information and understand that the permission can be revoked at any time by contacting Back2Back Cincinnati in written format either in email or letter.
Date(Required)
Provide the date of consent and submission of this form.
This field is for validation purposes and should be left unchanged.