Authorization Form
Name of Applicant (*)
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Date
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The following professionals or organizations have my permission to speak
with or release any pertinent information to the admissions office at J-CHAI:
Physician
Name
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Title
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Address
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City
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State
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Zip Code
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Phone
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Email Address
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Psychiatrist
Name
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Title
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Address
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City
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State
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Zip Code
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Phone
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Email Address
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Psychiatrist/Therapist
Name
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Title
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Address
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City
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State
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Zip Code
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Phone
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Email Address
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Regional Center
Name
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Title
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Address
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City
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State
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Zip Code
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Phone
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Email Address
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Educational Setting
Name
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Title
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Address
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City
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State
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Zip Code
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Phone
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Email Address
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Signatures
Applicant Signature
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Date
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Parent Signature
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Date
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Parent Signature
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Date
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Enter 4 letter code: Enter 4 letter code:
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