Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Guardian's Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Electronic Signature *

By entering your first and last name, you are signing this release of information form electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this release of information form. By entering your first and last name using any device, means or action, you consent to the legally binding terms and conditions of this release of information form. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Lowcountry Autism Foundation, Inc. You are also confirming that you are the guardian authorized to enter into this release of information for the above listed minor.

First Name

Last Name