I give permission for _____

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					                            Parker County Co-op
                    612 N. Rusk Weatherford, TX 76086
                    817-596-0024     FAX: 817-596-5297



I give permission for ___________________________________

to contact Early Childhood Intervention (ECI) services on my behalf and provide

the following information regarding my child:

Child’s Name________________________________

DOB ________________________________

Parent’s Name ___________________________

Home Address ___________________________

      City ______________________________            Zip Code _____________

Home Phone #_____________________________

Alternate Phone #__________________________

Concerns/Reason for referral:




_______________________________                 __________________________
Parent Signature                                Date




                                                                    March, 2007

				
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