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North Community Counseling Centers, Inc.Prevention Services: Worthington City Schools Parent/Guardian:Through a collaborative venture of the Worthington City Schools and North Community Counseling Center, we are able to offer your child prevention services, for no cost to the family. For your child to be eligible for this opportunity we are asking that you complete and sign the release of information form below.Once you have signed your child up with North Community Counseling Center, their Adolescent Coordinator will contact you to confirm registration for the back to school group. Once this step is complete, your son/daughter will be fully registered to participate in the back to school group.Once this form is complete please email to intake@ or fax to 614-267-7013. Please note that at any time you can withdraw your parent permission for your child to participate in this opportunity. Thanks for considering this wonderful opportunity to help your son/daughter grow socially, emotionally and academically. Please call, Michelle Meffley, LISW-S, 614-813-1083 if you have any questions or need clarification. My son/daughter, ________________________________, has my permission to participate in the North Community Counseling Partnership program.__________________________________________________________________ Date: ___________________Parent/Guardian required2339432599940Please check if you give permission for North Community Counseling staff to Communicate with school personnel. 267630105160Please check if you give Columbus Schools permission to release identifying Information in regards to your child.__________________________________________________________________ Date: __________________Parent/Guardian Signature required ................
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