EARLY CHILDHOOD EDUCATION PRACTICUM by H8469Q5

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									                        EARLY CHILDHOOD EDUCATION PRACTICUM

                                   RELEASE OF INFORMATION


    I,
                                   (Practicum Student’s Name)

                authorize Metropolitan Community College, Early Childhood Education

                                   Practicum Instructor, to disclose to

                                        Selected Practicum Site
                   (Name of person or organization to which disclosure is to be made)

    the following information:
   Disclosure results of Adult/Child Abuse Registry
   Academic history
   Emergency Contact Information
   Health Form

    The purpose of the disclosure authorized herein is to help the practicum site better understand the
    practicum student placed in this program.



                       Date                                 Signature of Participant



                                                       Signature of Parent, guardian, or
                                                            authorized representative, when required

								
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