Dream a Dream T.H. Consent to Release Information

This form is to be used when you are authorizing a person or facility to release information to D.a.D.T.H. or if you are authorizing D.a.D.T.H. release information to another person or facility.

I hereby authorize:

To release information from the records of:

This information is to be released to:

For the purpose of developing an equine activity program for the above-named participant. The information to be released is indicated below:

This release is valid for one year and can be revoked, in writing, at my request.