Consent For Information Sharing - Department Of Education (Page 2 of 2) in pdf

Consent For Information Sharing - Department Of Education Page 2

MODEL FOR THE COORDINATION OF SERVICES TO

CHILDREN/YOUTH

CONSENT FORM

I, ____________________________________________ declare that I am: [please check appropriate box]

(Name of consenting party)

The parent/legal guardian of ______________ who was born on the _______day of ______, _______

or,

a minor child, born on the ________day of _______, _________, who is 16 years of age or older and who

has withdrawn from parental control; or

19 years of age or older.

I HEREBY GIVE MY PERMISSION to (a) representative(s) of:

the Department of Health and Community Services

the Department of Justice

the Department of Human Resources, Employment and Labour

the Department of Education

other (please specify) _______________________________

[please check appropriate boxes]

to:

Release/share relevant information with members of the ISSP Team

Release to _________________________, the following information

(Describe information)

Obtain from ________________________________________________________________

(identify Department or agency)

the following information _______________________________________________________________

(Describe information – be specific)

Complete Child/Youth Profile for submission to the Regional Child Health Co-ordinator

which is necessary for the development/implementation of the Individual Support Services Plan.

I understand that the information which is the subject of my consent shall be treated as confidential and will only

be shared to the extent necessary to develop and/or implement the individual support services plan. This

information will only be disclosed in accordance with federal/provincial laws and will not be shared with any

other person or agency without my consent except in accordance with such laws and with any interdepartmental

protocols on the sharing of information.

This consent is given of my own free will and shall be valid for ________________________________

unless withdrawn by me in writing.

(Period of time) – not to exceed 1 year

Date: ___________________________

Signature of Consenting Party: ______________________________

Witness: ________________________________

January 2002

Consent For Information Sharing - Department Of Education Page 2