Consent for the Collection and Release of Information
Merrick Community Services programs are funded, in part, by Greater Twin Cities United Way (GTCUW) and/or Minnesota Department of Employment and Economic Development (DEED). Merrick is asking for your consent (permission) to release data that you provide to GTCUW and/or DEED to assess and improve the overall impact of Merrick programs.
This data cannot be released without your consent. GTCUW and DEED will not share your personal information with any other government agency or private institution. Your permission authorizes Merrick to collect and release the following information to GTCUW and DEED:
¨ Name
¨ Date of birth
¨ Social Security number
¨ Gender
¨ Race/ethnicity
¨ Felony conviction/ incarceration
¨ Housing status
¨ Education status
¨ Employment status including wage information
You will not be denied services or treated differently if you choose not to give permission to Merrick to collect and share your personal information. If you change your mind and decide you no longer want this data shared you must notify Merrick in writing. Data that has already been shared cannot be taken back. If you decide not to release this information, you may be contacted from time to time by Merrick program staff to ask about your employment status and wage information. Your consent to release this information is valid until 1 year after your exit from Merrick programs unless you notify Merrick in writing otherwise.
RELEASE OF INFORMATION CONSENT
_____ By initialing this line, I authorize Merrick Community Services to collect and release my information listed above to Greater Twin Cities United Way, MN Department of Employment and Economic Development, and Ramsey County Human Services for the purpose of evaluating the success of the program, including coordinated services in which I am enrolled and employment detail. I agree that I am under no obligation to grant such permission and that I am signing this release voluntarily.
PHOTO RELEASE CONSENT
_____ By initialing this line, I grant permission to Merrick Community Development to use photographs taken of me in print publications or in electronic forms or media, and to offer them for use or distribution in other publications, electronic or otherwise, without notifying me. I hereby agree to release, defend, and hold harmless Merrick Community Services, its agents or employees, including any firm publishing and/or distributing the finished product, from and against any claims, damages or liability arising from or related to the use of the photographs.
Name of Client ____________________________________
Name of Legal Guardian _____________________________
Signature of Client _________________________________
Signature of Legal Guardian __________________________
Intake Staff Signature ______________________________
Date _____________________________________________