The purpose of this release is to protect the privacy of information concerning individuals by placing restrictions on the disclosure of information contained in an individual record. By signing this release, you consent to allow the staff members of Orangewood Foundation to review and discuss any information contained in your records related to or impacting your participation in the program with administrators, social service staff members, mentors and foster care administrators or their staff members.
Your consent to release information begins at the time of application to the Mentoring Service. The release remains in effect until you officially exit the program. You may send a written letter revoking this release to the staff of Orangewood Foundation.
HOW WILL THE RELEASE BE USED? There may be situations where we need to request or relay information related to your application or participation in the program. This release allows us to discuss your personal information with staff members as well as the social service agencies familiar with your case history. In addition, this release grants authorization to the Oranegwood Foundation staff to request information from your mentor and his/her staff. Finally, this release allows Orangewood Foundation to discuss your record with professionals who are studying the issues related to former foster youth. Individuals other than staff members will sign a statement confirming that your information will be handled in a manner that does not permit identification of your personal situation. In all cases, your information is handled with confidentiality; your information will be destroyed when the data is no longer needed to document your activities.
MAY I RESCIND THIS RELEASE? To rescind this release, please send a written statement to Orangewood Foundation that includes your: Full name Date of birth Social security number Statement to rescind the request (please include effective date) Signature and date
WHAT IF I HAVE ADDITIONAL QUESTIONS? Orangewood Foundation staff are available to answer your questions during normal business hours. You can reach Orangewood Foundation by calling (714) 619-0200.
CLARIFICATION: By signing this release, I understand that information contained in my records related to or impacting my participation in the Mentoring Service may be released to or forwarded by Orangewood Foundation staff with my FULL CONSENT. I have signed this release for the purpose of coordinating my participation in the Mentoring Service. I understand that this release will remain in effect until I officially exit the program. I understand I can withdraw this authorization by sending a written letter revoking this release to Orangewood Foundation prior to that date. I understand that this release exempts Orangewood Foundation staff from adhering to confidentiality statements I may have signed regarding my records. I certify that all of the information reported on this form is true, complete and accurate.