Child's Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

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.

English

Spanish

American Sign Language

Other

Language Interpretation Services Needed

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.

Male

Female

Intersex

Decline to Answer

By checking this box I acknowledge I am providing an electronic signature.

Option One

Option Two

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.

First Name

Last Name

Date of Electronic Signature

MM

DD

YYYY