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