Directions For Completing Medical Requirement Forms (Page 8 of 8) in pdf

Directions For Completing Medical Requirement Forms Page 8

Consent to Collection of Personal Health Information

I, _________________________________ (name) hereby consent to the collection of my personal

health information by the Union of Ontario Indians, operating as the Anishinabek Educational Institute.

I understand that this may include my immunization history, health history, ongoing health information,

and any other information necessary to ensure my ongoing ability to complete the RPN program.

I further understand that my personal health information will be maintained according to the standards

and principles of the Personal Information Protection and Electronic Documents Act and Personal Health

Information Protection Act, as applicable.

I further understand that this consent is voluntary.

I further understand that I may request to review my personal health information or revoke this consent

at any time by informing the Union of Ontario Indians in writing.

Student’s Signature __________________________________ Date: ____________________________

Witnesses Signature: ________________________________ Name: ____________________________

Medical Form

Page 8

Directions For Completing Medical Requirement Forms Page 8