The purpose of this form is to give us permission to receive information from other professionals who work with your child. This allows us to better know your child during the application process and helps us determine whether or not Camp Akeela will be a good match for him/her. In addition, should your child attend Akeela, we will have the opportunity to communicate with those who know your child best throughout the summer. We will also be happy to share information about their camp experience with these same professionals once the summer is over.

IMPORTANT: Please ask the people listed below to complete the Professional Questionnaire portion of our online application on your child’s behalf. After receiving their written questionnaire, we will follow up with them as needed.

I, the undersigned, do hereby give my permission for Camp Akeela and the following list of agencies or individuals to share information about my child:

Camper Name *

First

Last

Camper Birthdate *

Professional 1

(School Professional)

Name *

First

Last

Professional Title *

Length of Relationship *

Email *

Phone *

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Professional 2

(Mental Health Provider, if applicable. If none, provide information for another professional who works with your child)

Name *

First

Last

Professional Title *

Length of Relationship *

Email *

Phone *

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Professional 3

Name *

First

Last

Professional Title *

Length of Relationship *

Email *

Phone *

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

I understand that this information will be kept confidential by Camp Akeela and will not be released to any agencies or parties not listed above without further consent.

Parent / Guardian Signature *

Clear Signature

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