Victory Hill Dorm Video and Technology Use (CF4082)

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The personal information collected on this form will be used for the purpose of service plan and evaluation and will be treated confidentially in compliance with the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information please contact the Director, Provincial Deaf and Hard of Hearing Services at (604) 660-1800 (voice), (604) 660-1807 (TTY), 4334 Victory St, Burnaby BC, V5J 1R2.

Consent to video use/online technology: PDHHS staff and clients may use video technology (such as Video Relay Service, Skype, FaceTime, GoToMeeting, MS Teams and Zoom) to communicate and receive services (for example, communicating by video, and sign language instruction). If you provide your email address it may be used to communicate with you regarding these services. Personal information about clients will be collected throughout these processes. PDHHS staff cannot guarantee that internet-based technology (video or otherwise) is 100% secure - personal information may be transmitted, collected, and/or stored via the internet. Servers for these video services and some sign language interpreters (if you are using the Video Relay Service) may be located outside of Canada. Clients may consent to proceed with video services/online technology or decline. For clients who decline video services/online technology, other service options will be explored (for example, by phone or in-person sessions).
 
This consent is valid from the date this document is signed, until consent is revoked by contacting Provincial Deaf and Hard of Hearing Services at pdhhs@gov.bc.ca
 
Information collected by PDHHS while using video services/online technology or accessing services through other means is collected per section 26(c) of Freedom of Information and protection of Privacy Act (FOIPPA) for the purposes of delivering services to clients. If you have any questions about the information here, please contact:
 
Rebecca Storey, Director,
Provincial Deaf and Hard of Hearing Services,
Ministry of Children and Family Development
4334 Victory Street,
Burnaby, BC, V5J 1R2,
604-660-1800

You can add as many signatures as are needed, by clicking on the arrow under the plus (+) sign at the top left of the signature block, and you can also remove a signature block, or reorder the signatures, from the same menu.
 
Use your mouse, or finger if you're on a phone or tablet, to sign in the Parent/Guardian's Signature field.
By signing below, I give my consent to use video/online technology for service delivery:
Date Signed (MM/DD/YYYY)
Parent/Guardian's Signature
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Parents can sign on behalf of their children 12 and over if they are deemed incapable.
 
Consent can be withdrawn at any time - simply notify PDHHS.

By clicking submit you will sending your application electronically to the Victory Hill Dorm Manager.
 
If you prefer to print and mail your application, click the PDF button to generate a printable version.
Mail to:
Victory Hill Dorm, c/o Patrick Tarchuk
4334 Victory Street
Burnaby BC V5J1R2
 
Please mark the envelope CONFIDENTIAL.

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