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Goodwill:
Industries of Wayne and Holmes Counties, Inc.
Name
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DATE
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Month
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Day
Year
Date
This release is valid for six-months or until
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Month
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Day
Year
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 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 Services
Anazao
Opportunities for Ohioans with Disabilities
Legal Representative
Court Appointed Probation/Parole Officer
Counseling Center
One Eighty
Salvation Army
Community Action
Village Network
Children Services
Child Support
Employer (Valid One year after program exit)
Educational Institution (valid until 1 year following program exit)
OMJ email username and password
Military
Gmail and OMJ username and password
United Way
Homeward Bound
Other
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
*
Phone
Letter
Fax
Email
Face-to-Face
Client or Guardian Signature
*
Date
*
/
Month
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Day
Year
Date
If Guardian signed for client please enter their name
Date
-
Month
-
Day
Year
Date
NOTE: THIS CONSENT FORM CAN BE REVOKED AT THE REQUEST OF THE CLIENT
Select the method that was used to complete form
*
Please Select
This form was completed in person with the client
This form was not completed in person with the client
Case Manager Name
*
Date
*
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Month
/
Day
Year
Date
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