NOMINEE CONSENT FORM Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.I am filling this out *on behalf of a child in my careas an adult for myselfParent/Guardian Name *FirstLast Number withdraw care. Client Name *FirstLastEmail *Phone *By signing this form, I authorise the below organisations and/or professionals to disclose and receive relevant information that is necessary to support my treatment and care. *I agreeBy signing this form, I authorise the below organisations and/or professionals to disclose and receive relevant information that is necessary to support my child's treatment and care. *I agreeI understand that providing consent is voluntary, and that I may withdraw this consent at any time by providing written notice. *I agreeContact Details for Nominated Person 1: Nominee's Name *FirstLastNominee's Email *Nominee's Number *Position *Contact Details for Nominated Person 2: Nominee's NameFirstLastNominee's EmailNominee's NumberPosition *Consent: Signature * Clear Signature Full Name *FirstLastRelationship *Today's Date *Submit
