Connexions Training 1400 Chapel Street. PO Box 782Santa Clara, UT 84765(801) 874-7691 AUTHORIZATION TO RELEASE INFORMATIONI,Fullname* * whose birthdate isBirthday* MM slash DD slash YYYY *hereby authorize Connexions Training Staff to: Release Information To (the Person you want Jodi/Connexions Training Staff to interact with)* Mailing Address:* Street Address City State / Province / Region ZIP / Postal Code Phone:*Alternate Phone:*Email* Relationship to Client:* It is requested that the following specific information be provided: YOU MUST INITIAL THE LINES BELOW. All Session Related Information and Scheduling*Any & All Financial Information Released to Third Party*My Goals and Results*others*Coordination with other Service Providers*In consideration of this consent, I hereby release Jodi Hildebrandt, Connexions Training and Connexions Classroom Inc. and it’s staff from any and all liability arising therefrom.Client or Guardian Signature:*Date:* MM slash DD slash YYYY HiddenCountryHiddenCityHiddenProvinceHiddenLatitudeHiddenLongitudeHiddenTimezoneHiddenContinent