Consent to Release Personal and Confidential Information

I hereby authorize the following Practitioner or Medical Practice to disclose to Anasazi Foundation the following information regarding the following participant in the Anasazi Program:

1. Physical examination including urine dipstick
2. TB and blood tests (including, but not limited to Serum Pregnancy Test, CBC, CMP)
3. Copy of immunization records
4. Copies of current prescriptions currently being taken

The purpose of the disclosure authorized herein is to ensure the appropriateness of the wilderness treatment program and to ensure the safety of the above-named participant while enrolled in the wilderness treatment program.