Consent to Apply to ACCES-VR

The University of the State of New York

THE STATE EDUCATION DEPARTMENT

Office of Adult Career and Continuing Education Services (ACCES-VR)
Authorization to Release Information
Name:*
The Office of Adult Career and Continuing Education Services (ACCES-VR) has my permission to release or obtain information from agencies [including the Client Assistance program (CAP)], individuals, or employers as are concerned with my vocational rehabilitation. This information may include reports about my physical or mental condition, official school records, facts necessary to determine my financial need, or other information that ACCES-VR needs to determine my eligibility and to provide vocational rehabilitation services.

All such information will be treated as confidential and privileged;

The information will be used only for the purpose of obtaining services offered through

I can withdraw my permission to release or obtain information by writing to ACCES-VR (this will not affect actions already taken with my permission); and

ACCES-VR may need to use the information to administer the vocational rehabilitation program
Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature (If Under 18 Years of Age) Date

Clear
Parent/Guardian Signature (If Under 18 Years of Age) Date

MonthDayYear
Date
The State Education Department does not discriminate on the basis of age, color, religion, creed, disability, marital status, veteran status, national origin, race, gender, genetic predisposition or carrier status, or sexual orientation in its educational programs, services, and activities. Inquiries concerning this policy of nondiscrimination should be referred to the Department’s Office for Diversity, Ethics, and Access, Room 530, Education Building, Albany, NY 12234-0001.
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Authorization to Release Information