12 Maple Ave
Foxboro, MA 02035
781 806 5707
Information Release
This is to authorize any physician, hospital, firm, organization or person to furnish to Maplewood Assistance Partners, Inc. all information, material or opinions which may be requested by Maplewood Assistance Partners, Inc. concerning me. Maplewood Assistance Partners, Inc. is further authorized to copy any X-rays or other records pertaining to me. I hereby waive any privilege I have to said information to Maplewood Assistance Partners, Inc.
The Information requested by Maplewood Assistance Partners, Inc. will be used by them to evaluate my application for a service dog and training in the use thereof.
Applicant's signature______________________________________ Date_________________
Applicant's name ________________________Phone_________________
Street Address_____________________________________
State:__________ ZIP:____________
Or if applicable
Parent/Guardian signature____________________________________Date_________________
Parent/Guardian name____________________________________Phone___________________
Street Address_________________________________________________________________
City________________________________ State__________ Zip Code__________________