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Family Outreach

DVD from Mom/Dad Permission Slip


Certification and Release Statement

Are you the legal guardian of child(ren)?
I authorize investigation of all statements contained in this document as may be necessary in my child(ren) receiving a DVD from Mom/Dad.
I certify that the information given herein is true and complete and that submission of this form is the same as my signing this form.
I authorize by submitting this form, a DVD will be sent to the above address.

Questions? Please call or text Andi at 402-805-1143 or email her at andib@chne.org.

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