Opt-Out Form | Leonard Parker Pool Institute

The Allentown Health Bureau, Community Services for Children, Valley Health Partners, Lehigh Valley Health Network including Lehigh Valley Reilly Children’s Hospital, Leonard Parker Pool Institute for Health and Pool Center for Health Analytics have launched a new collaborative that aims to create an equitable early learning environment for young children in Allentown, particularly in the Franklin Park neighborhood. These partners are committed to working together in new and innovative ways to reduce barriers to services that families rely on with the goal of supporting healthy early development.

If you have previously granted your permission to use information about your child in support of the collaborative’s mission, you may opt out of this initiative at any time. If you no longer wish to allow your child’s data to be used for this initiative, please complete the survey below to opt out.

Child First Name

Child Last Name

Child Date of Birth

Child Gender

Male

Female

Other

Guardian First Name

Guardian Last Name

Guardian Date of Birth

Relationship to Child

Guardian Zip Code

Guardian Email address

Guardian Phone Number

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