Pastor John LaGalbo
Director
2330 Highway 120
Lake Geneva, WI 53147

Mt. Zion House

Fax: (262)249-8903
Tele: (262)249-8934

Informed Consent for the Release of Student Information

I, _________________________ give the Mt. Zion House staff my permission to release information concerning myself. The release of this information is only to the following individuals listed below. And I give the Mt. Zion House staff my permission to release information to these individuals at their discretion. This information may be released beginning now and up until 60 days after my departure from the Mt. Zion House program.

Signed______________________________Date___________________________________

Names of individuals that information may be released to are -

__________________________________ _______________________________________

__________________________________ _______________________________________

__________________________________ _______________________________________

__________________________________ _______________________________________

__________________________________ _______________________________________