RELEASE OF INFORMATION
AND CONSENT OF TREATMENT

 
IMG/Bollettieri Academy Parents ONLY
Child/Student Name (first, last):
Parent or Guardian Name:
Name of individual submitting
this electronic form:
Relationship:
Date of Birth (mm/dd/yyyy):
Today's Date (mm/dd/yyyy):
   
Release of Information and Consent for Treatment:
 
By clicking on “Submit”, I hereby provide my authorized electronic signature for the above release of information and consent to receive service described above: