H & H Child Care Training

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H&H Release of Information Form

Effective Date: 06/2016

Processed Date: ________

H&H Release of Information Form

Upon submission of a completed H&H Release of Information Form, from the applicant by signature only, records will be released and forwarded within a period of 7 to 14 business days, based on need. Expedited records may be requested for an additional fee.

I ____________________________, give permission for H&H Child Care Training Center LLC to share and exchange information with other staff at __________________________ for the purpose of providing assistance to me. ______ (initial)

I, ______________________________, give permission to H&H Child Care Training Center LLC to share information with the following service agencies for the purpose of providing assistance to me. ______ (initial)

List names of agencies below:          

_________________________________________________________________

_________________________________________________________________

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I confirm that I have reviewed the H&H POLICY ON RECORDS, RELEASE AND PRIVACY on the website www.ChildCareEd.com  and I understand its content. My signature below indicates my consent.

Signature _______________________________________________      Date ___________________