Consent to Evaluate signature

Consent to Evaluate Agreement

Childs Name

First Name

Last Name

Childs Date of Birth

MM

DD

YYYY

Todays Date

MM

DD

YYYY

By entering my initials below, I acknowledge my voluntary participation, and my child’s participation, in this assessment by Kara S. Schmidt, PhD. I understand that we may withdraw from the testing at any time and that my records may not be released to outside parties without my written consent except as outlined in the "consent to evaluate" form by the limits of confidentiality.

Enter initials below