Becoming a LAF Family is easy. Simply complete the contact and release forms and return via email, mail or fax. After completing the contact and release forms, families will have access to all LAF programs and services.

Child's Name *
Child's Name
Parent/Guardian Name *
Parent/Guardian Name
Phone *
Phone
Address *
Address
Date of Birth *
Date of Birth
If you are seen by an MUSC physician, please list their name here. If you are not seen at MUSC, please leave blank.
Preferred Spoken/Written Language
We require the following information for the purpose of helping our staff use the most respectful language when addressing you, understanding our population better, and fulfilling our grant requirements. The options for some of these questions were provided by our funders. Please help us serve you better by selecting the best answers to these questions. Thank you.
We require the following information for the purpose of helping our staff use the most respectful language when addressing you, understanding our population better, and fulfilling our grant requirements. The options for some of these questions were provided by our funders. Please help us serve you better by selecting the best answers to these questions. Thank you.
Sex Assigned at Birth
We require the following information for the purpose of helping our staff use the most respectful language when addressing you, understanding our population better, and fulfilling our grant requirements. The options for some of these questions were provided by our funders. Please help us serve you better by selecting the best answers to these questions. Thank you.
Lowcountry Autism Foundation has permission to Request and/or Release information contained in the Medical Record of the above named patient and may provide and/or request information from the following parties.
By checking this box I acknowledge I am providing an electronic signature.
Electronic Signature of Guardian *
Electronic Signature of Guardian
I hereby authorize LAF to release any medical information as requested above. This may include information about care/treatment received by my child at LAF. I understand that information used or disclosed under this authorization may be subject to re-disclosure by the recipient without being further protected under the HIPAA rules. I am aware that LAF cannot control how the recipient uses/shares the information, and that laws protecting its confidentiality at LAF may or may not protect this information once it has been disclosed to the recipient. I understand that LAF will continue to provide care if I do not authorize this release. Information will be released with a valid signature.
Date of Electronic Signature
Date of Electronic Signature