I also authorize the Listen to Me! Conference to contact me at the above phone number and addresses with correspondence that specifically relates to the Listen to Me! Conference.
This authorization shall expire no later than exactly one year after I submit this application or upon termination of my child’s enrollment in the Listen to Me! Conference (whichever is sooner). I understand that I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing. I understand that the revocation will not apply to information that has already been released in response to this authorization. By signing below I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information.