I hereby attest that I am the legal guardian of the child (date of birth ),and am thereby empowered to make all decisions pertaining to this child’s health and educational needs, including the provision of psychological and neuropsychological services. In addition, I attest that no court order or custodial agreement limits my powers in this regard or requires additional consent from another party.

Name:*

Date:*

Signature:*

In the space below, please provide the name, address, and telephone number of parents/guardians residing elsewhere:

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Dr. MoldoverDr. HebertDr. Benetti-McQuoid