Consent Form

Consent Form
Name*
DATE*

MonthDayYear
Date
This release is valid for six-months or until*

MonthDayYear
Date
I agree to the release of only the information specifically outlined below. I further consent that unless otherwise stated, this release will stay in effect for employment and education verification, educational records and student information until 1 year following program exit. I will sign a separate release if this information must be released to an organization/agency or persons other than the ones named below. I also consent to the agency’s use of remote communication for training and meeting purposes including the use of video technology.*

Department of Job and Family ServicesAnazaoOpportunities for Ohioans with DisabilitiesLegal RepresentativeCourt Appointed Probation/Parole OfficerCounseling CenterOne EightySalvation ArmyCommunity ActionVillage NetworkChildren ServicesChild SupportEmployer (Valid until 1 year following program exit)Educational Institution, records & student information (valid until 1 year following program exit)OMJ email username and passwordMilitaryGmail and OMJ username and passwordHomeward BoundUnited WayOther
Information to be released (be specific) To obtain and/or provide referral information, social, financial, historical, psychological, legal, and medical that will assist the agencies for the above named to gain employment in the community. Information shall be released by any of the below mediums*

PhoneLetterFaxEmailFace-to-Face
Client or Guardian Signature*
Date*

MonthDayYear
Date
If Guardian signed for client please enter their name
Date

MonthDayYear
Date
NOTE: THIS CONSENT FORM CAN BE REVOKED AT THE REQUEST OF THE CLIENT
Select the method that was used to complete form*
Case Manager Name*
Date*

MonthDayYear
Date
Should be Empty:

Consent Form

NOTE: THIS CONSENT FORM CAN BE REVOKED AT THE REQUEST OF THE CLIENT