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 them. In addition, should your teen attend Beyond Akeela, 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.

REQUIRED: Please include at least one school professional, and your teen’s mental health provider if they have one.

IMPORTANT: Please ask the professionals listed below to complete the Professional Questionnaire 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 Beyond Akeela and the following list of agencies or individuals to share information about my teen:

Your Teen's Name: *

First

Last

Your Teen's Birthdate: *

Professional 1

(School Professional)

Name: *

First

Last

Professional Title: *

Length of Relationship *

Email: *

Phone *

Professional 2

(Mental Health Provider, if any. If none, please provide information for another professional who works with your teen.)

Name: *

First

Last

Professional Title: *

Length of Relationship: *

Email: *

Phone: *

OPTIONAL - Check the box below if you'd like to add a 3rd professional to the Release Form

• Add 3rd Professional

Professional 3

Name: *

First

Last

Professional Title: *

Length of Relationship: *

Email: *

Phone: *

I understand that this information will be kept confidential by Beyond Akeela and will not be released to any agencies or parties not listed above without further consent.

Parent / Guardian Signature *

Clear Signature

SubmitSave and Resume Later