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DocuSign Envelope ID: D6EB45D6-6C12-4C2B-895B-067AF17D828F <br /> Please complete sections A or B, as appropriate, and sign C below. <br /> A. For Parent/Guardian of minor child (please print clearly) <br /> Parent/Guardian First Name Parent/Guardian Last Name <br /> As the (circle one) Parent, Guardian, or in loco porentis of <br /> Print Child's Legal First Name Print Child's Legal Last Name <br /> authorize the release of personally identifiable health information of the Child named above, subject <br /> to the terms of this Consent Agreement. <br /> B. For Adult of legal age(please print clearly) <br /> I, , <br /> Print First Name Print Last Name <br /> authorize the release of my personally identifiable health information, subject to the terms of this <br /> Consent Agreement. <br /> C. By signing this Consent Agreement, I agree that I have read and understood the above and consent <br /> to all of the above statements. I understand that signing this Consent Agreement is voluntary and is <br /> not a condition for receiving services from Orange County FSA.This Consent Agreement is valid for <br /> the duration of the Orange County FSA initiative. I maintain the right to discontinue this permission at <br /> any time by contacting the Orange County FSA Site Manager at <br /> Signature Date <br /> For Orange County FSA Use Only <br /> Partner collecting this consent agreement: <br /> Consent record recorded in Orange County FSA Site on (date): <br /> Orange County FSA case management number: <br /> 20 <br />