Victory Hill Dorm Release of Information (CF4081)

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Victory Hill Dorm Release of Information

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.

Child/Youth

Last Name

First Name

Consent

I, do hereby authorize the designate representatives of the Victory Hill Dorm Staff to communicate with the professional/programs listed below for the purpose of planning and coordinating supports for my child/youth:

Other

Specify

Note: The consent will not exceed 12 months from the date consent is given.

I hereby waive any and all claims against MCFD Provincial Deaf and Hard of Hearing Services and its employees for all purposes whatsoever arising from the disclosure of information. The agencies/persons receiving the information are expected to treat all information as confidential.

Parent/Guardian's Name

Date Signed (MM/DD/YYYY)

Parent/Guardian's Signature

NOTE: Any written information that does not appear on a line on this form automatically void the validity of the form. Consent may be withdrawn at any time at the client/family's request.