Legal Guardian *

By typing in my name here, I acknowledge that it is taking the place of my handwritten signature.

First Name

Last Name

I, the Legal Gaurdian, give permission for Cynthia R. Dodd, M.A., to work with (Minor Child) *

Yes

Name of Minor *

First Name

Last Name

in the role of counselor/therapist at Level Ground Christian Counseling. I have been provided the informed consent and agree to the conditions contained therein. *

Yes

No

Date

MM

DD

YYYY