General Release of Information

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I hereby authorize an exchange of information between Big Brothers Big Sisters Southern Lake Michigan Region and the professional/organization listed below to discuss my child's records indicating perceived strengths and challenges, including but not limited to, my child's behavior, personality, and interests.
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I give this authorization to Big Brothers Big Sisters Southern Lake Michigan Region with the understanding that it will be used in a confidential manner. Information released may be used to evaluate the suitability of my child to be matched in the BBBS program or to provide advocacy/referral of services on behalf of myself or any member of my household. I authorize those cited above to confer as necessary to establish an accurate exchange of information. 
I understand that I can revoke this consent at any time by giving written notice to the person/organization making the disclosure. Big Brothers Big Sisters Southern Lake Michigan Region is not liable for items sent in the interim between authorization and revocation.

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