PLEASE PRINT CLEARLY

Please be advised that a new federal privacy law went into effect on April 21, 2003. It provides more stringent guidelines for the release of even the most basic medical information.
It has been the practice of the Barnard Babysitting Service to confirm that your child is a patient of the pediatrician you have indicated. No other information is requested other than the attached confirmation, and we do not share this information with others. Thank you.

Sincerely,
Alison Powell
Manager, Barnard Babysitting Agency

PLEASE FILL THIS FORM OUT COMPLETELY AND RETURN IT WITH YOUR CONTRACT AND CHECK TO:
Barnard Babysitting Service
C/O Office of Career Development
3009 Broadway
New York, NY 10027

Parent's name___________________________________________________________
Home Phone ___________________________________________________________
Address ______________________________________________________________
Pediatrician's Name _________________________________
Address ____________________________________________
Child(ren)'s name(s)___________________________________ DOB __________

___________________________________________________ DOB __________

___________________________________________________ DOB __________

I give permission that the above named pediatrician(s) may verify that the above listed children are currently registered patients at her or his office.

____________________________
Signature of Parent - Date

____________________________
*Signature of Physician - Date

*Registration cannot be processed without this signature. If necessary, only birth certificates or immunization records may be substituted. Please attach a copy to the contract.