Record Release Form 1 "*" indicates required fields Authorization for Release of InformationName* Is authorized to release information or records about:Last Name* First Name* Middle Initial* Address City State Zip Code Phone Number*If release is for information about dependent child(ren), list name(s) of dependent child(ren):Specific information to be used or disclosed: CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
