I hereby authorize any physician, hospital, or organization having any records or information concerning me to furnish such data or information as may be requested by the Kansas Braille Transcription Institute Training Program or its duly authorized representative. A photocopy of this authorization shall be considered as effective and valid as the original.

I understand that all information obtained y the Kansas Braille Transcription Program is confidential and my right to privacy will be insured.
I Agree

Applicants Name
Date
Witness
Witness Date