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Release of Information

Form authorizing staff of The Maddux School to request, receive and/or provide confidential information

Name of Child *

Name(s) of Professional(s)

Name	Organization	Phone	Email

Additional Notes:

I hereby authorize staff of The Maddux School to exchange information concerning my child's education, care, and treatment with the above professional(s).

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Please note this authorization expires one year following its submission unless otherwise specified.