Create a Website Account - Manage notification subscriptions, save form progress and more.
to request and receive my Montgomery County Children and Youth records.
I understand these records contain confidential information, and I am waiving that confidentiality below.
By allowing a 3rd party (PERSON RECEIVING THE RECORDS) to request and receive records on my behalf, I am waiving the confidentiality of my Children and Youth records. I understand these records may contain information regarding drug and alcohol treatment, mental health treatment, and other protected information. I am authorizing that information to be released to the Company/Person listed below.
Enter your Initials authorizing that information to be released to the Company/Person listed below.
This release is valid for 1 year from the date signed below. If you wish to cancel this release, please send a letter or email revoking the authorization to:Montgomery County Children and YouthC/O Dionna Sanders, P.O. Box 311 Norristown, PA 19403
This field is not part of the form submission.
* indicates a required field