Beyond Akeela Application: Release

    PART II - Permission for the release of information.

    Fields marked with an asterisk (*) are required.

    The purpose of this form is to give us permission to receive information from other professionals who work with your teen. This allows us to better know your teen during the application process and helps us determine whether or not Beyond Akeela will be a good match for him/her. In addition, should your teen attend this camp, we will have the opportunity to communicate with those who know your teen best throughout the summer. We will also be happy to share information about your teen's camp experience with these same professionals once the summer is over.

    IMPORTANT: Please ask the people listed below to complete Part IV of our online application on your teen's behalf. After receiving their written questionnaire, we will follow up with them as needed.

    I, the undersigned, do hereby give my permission for Camp Akeela and the following list of agencies or individuals to share information about my teen: 

    *Camper Name:   
*Date of Birth:

    Teacher/Special Education Coordinator: 

    *Name:                   
*Professional Title:     
*Length of Relationship: 
*Address:                
*City:                   
*State:                  
*Zipcode:                
*Phone:                  
*Email:

    Psychologist/Mental Health Professional: (note: If your teen is currently seeing a psychologist or other mental health professional, he/she must be listed here. Otherwise, please use this space to provide us with the information for another professional involved with your teen.) 

    Name:                   
Professional Title:     
Length of Relationship: 
Address:                
City:                   
State:                  
Zipcode:                
Phone:                  
Email:

    Third Professional (Speech/language, OT, PT, an additional teacher, etc.): 

    Name:                   
Professional Title:     
Length of Relationship: 
Address:                
City:                   
State:                  
Zipcode:                
Phone:                  
Email:
    I understand that this information will be kept confidential by Camp Akeela and will not be released to any agencies or parties not listed above without further consent.

    *Parent/Guardian Signature:
    (Type in full name as signature.)

    *Parent/Guardian Email:

    *By submitting this form I am granting permission to Camp Akeela to speak with the above professionals about my teen.

    I AGREE

    When you are finished, please hit the submit button only once.
    Thank you!