Release of Information

RELEASE

Release of Information and Permission to Participate

My name is:

I am the legal guardian of:

I give my permission for participation in the Lipstick After Dark Mentoring Program. Specific to the following activities:

on-site meetings in youth’s current living situation off-site group meetings authorized by youth’s current living situation off-site group meetings authorized and hosted by L.A.D. MENTORING. off-site individual activities with mentor

I give my permission for authorized LIPSTICK AFTER DARK, LLC staff to speak with care-givers (therapists, social workers, current living situation personnel) if needed.

Yes No

Phone Number

By selecting the box below, I attest to the truthfulness of all information listed on this form and agree to all the above terms and conditions.

I accept

RELEASE

Release of Information and Permission to Participate

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