Consent for Release/Exchange of Information By signing this form, I am providing my consent for _ (Program Provider) _ to release, obtain and/or exchange information and/or records with the agencies / persons listed below. I understand that without my consent, _ (Program Provider) _ cannot release or obtain information to/from agencies or individuals. Participant Name: Student I.D.: Date of Birth: _ The purpose of this information exchange/release is to: □ □ □ Monitor progress of employment plan Monitor progress of credentialed training Ensure completion results are accurately plan captured Eligible Training Provider (School Name) requesting or releasing information Name of School: Student Records Phone Number: ( ) – Street Address: Student Records Fax Number: ( ) – City: State: Zip: Program provider requesting or releasing information Return to: ( Program Provider’s Name ) Main Phone Number: ( ) Main Fax Number: ( ) – – Information to be released (Initial all that apply) □ □ □ All records Attendance records Grades/transcripts/class schedule □ □ □ Academic status/progress Copy of diploma/GED/certificate/Credential Financial aid information □ □ School payment information Other (specify): *If there is a charge for the release of the requested information, please notify the requester before sending the information. I have been informed of the intended purpose and use of the information that will be released. I understand that the information provided by the above-named providers, organization, or agency will not be shared with others without my consent, except as permitted under state or federal laws that govern activities of the requester. By signing this form, I waive any claim I might otherwise assert against any individual, organization, or requester for any action that may result from the release of any information. I understand that I may revoke this consent by giving written notice to__ [Program counselor]_ (not retroactive), and that this consent will automatically expire one year after I exit the program. Date: Participant Signature: Parent/Guardian Date: Signature (If under 18): Employment Counselor Date: Signature:
Consent for Release/Exchange of Information By signing this form, I am providing my consent for _ (Program Provider) _ to release, obtain and/or exchange information and/or records with the agencies / persons listed below. I understand that without my consent, _ (Program Provider) _ cannot release or obtain information to/from agencies or individuals. Participant Name: Student I.D.: _ Date of Birth: The purpose of this information exchange/release is to: □ Monitor progress of employment plan □ Monitor progress of credentialed training plan □ Ensure completion results are accurately captured Eligible Training Provider (School Name) requesting or releasing information Name of School: Student Records Phone Number: ( ) – Street Address: Student Records Fax Number: ( ) – City: State: Zip: Program provider requesting or releasing information Return to: ( Program Provider’s Name ) Main Phone Number: ( ) – Main Fax Number: ( ) – Information to be released (Initial all that apply) □ All records □ Attendance records □ Grades/transcripts/class schedule □ Academic status/progress □ Copy of diploma/GED/certificate/Credential □ Financial aid information □ School payment information □ Other (specify): *If there is a charge for the release of the requested information, please notify the requester before sending the information. I have been informed of the intended purpose and use of the information that will be released. I understand that the information provided by the above-named providers, organization, or agency will not be shared with others without my consent, except as permitted under state or federal laws that govern activities of the requester. By signing this form, I waive any claim I might otherwise assert against any individual, organization, or requester for any action that may result from the release of any information. I understand that I may revoke this consent by giving written notice to__ [Program counselor]_ (not retroactive), and that this consent will automatically expire one year after I exit the program. Participant Signature: Date: Parent/Guardian Signature (If under 18): Date: Employment Counselor Signature: Date:
consentrelease.docx