I hereby give permission to the below professional(s), including but not limited to, counselor, therapist, agency or school, to release information on:

Child's First Name

Child's Last Name

Child's Date of Birth

Professional's Contact Information

Contact Name (First & Last)

Contact Phone Number

Contact E-mail

I give this authorization to Big Brothers Big Sisters ("BBBS") with the understanding that it will be used in a confidential manner. Information released will be used to evaluate the suitability of the above names person to be matched in the BBBS program. I authorize those cited above to confer as necessary to establish an accurate exchange of information.

Parent/Guardian Printed Signature

Today's Date

Parent/ Guardian Email Address

Child's Date of Birth

Contact Information