Comprehensive Career Services Consent Form

Student's Full Name

First NameLast Name

Date of Birth

Date

Primary Language

Gender

Race

Ethnicity

Please check the following statement.

Please indicate your disability.

Parent/Guardian Name

First NameLast Name

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

City

State

Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

School/Learning Institution

Please Indicate the service(s) you are requesting

By signing below, I acknowledge that I am requesting Comprehensive Career Services based on the criteria that I am a student with a disability. I understand that I will need to meet with a provider and develop a service plan approved by MassAbility before I start receiving services. I understand that, as a recipient of services from MassAbility, I have a right to seek advocacy services from the Client Assistance Program at 1-800-478-1234 or http://www.dlc-ma.org/

Parent Signature

Student Signature