Dcfs Signature Release Form

Ascend Good Kids With Bad Behaviors 12641 South Vincennes, Blue Island, Illinois 60406  Phone: 708-597-3065 Fax: 866-883-9952  www.Ascend.nu  [email protected]

This release will authorize Ascend Counseling Limited to apply my signature electronically or to consider my typed name as my authentic signature when quarterly reports or other documents sent via email. Printed Name___________________________________ Signature______________________________________ Date of Authorization_____________________________ This authorization will be in effect until otherwise retracted.

Levins

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