• As the legal guardian for
  • I
  • give consent for the above-named individual to
  • from the site located at 1622 Turner St. Clearwater FL. 33756 (HSPFL).

    I further understand that I have to arrange transportation to pick him/her up so that they may leave without disturbing or interrupting the other children.

    I also understand that if named child leaves the premises without my signed consent that law enforcement shall be notified immediately by staff at 1622 Turner st (HSPFL).

    I understand that this consent is valid for one year and that I have the right to rescind this consent at any time.

    You have the right to revoke this authorization, in writing, at any time per HIPAA Privacy Policy 164.520, with the exception of those authorizations you signed for routine disclosures for treatment, payment or healthcare operations as permitted by the HIPAA Privacy Rule. HEADS will not condition your treatment, payment, enrollment or eligibility on whether or not you sign this release of information. Be advised that there is potential for your information to be redisclosed by the recipient and no longer protected by 45 CFR, Part 164, Subpart E.

    Under no circumstances is Turner St (HSPFL), its Staff or HEADS staff to be held responsible for named child's actions or behavior once they leave the premises of (HSPFL) regardless of whether the child has permission or not.

  • Date Format: MM slash DD slash YYYY