I hereby authorize Easterseals of the Birmingham Area (ESBA) to request from or release to Alabama Department of Rehabilitation and appropriate Easterseals staff members the following information: verbal, written, and/or electronic information and reports including but not limited to entry, progress, termination, closure, and case notes. The purpose and need for this disclosure is to inform the referring agency of performance while participating in any programs at Easterseals.
This consent may be ended at any time by the consumer, but ending the consent will no cancel any action that has already been taken place as allowed by this form. Unless the consumer wishes to cancel this consent at an earlier time it will automatically stop upon the date and/or condition indicated.
It is understood that the duration of this consent will not be longer than would be necessary and reasonable to carry out the purpose of which it is given.
I have received the "Easterseals Consumer Handbook" and an Easterseals of the Birmingham Area staff member has explained it to me. I have also received safety instructions regarding fire and natural disaster procedures. I understand my rights and responsibilities and agree to participate in my vocational program. In order to speed up the employment process, each of us has a duty to accept and carry out the following:
Person Served (Consumer)
The following signatures indicate that the program expectation agreement has been reviewed with and accepted by the consumer and staff.
I HEREBY GIVE Easterseals of the Birmingham Area the absolute and irrevocable right ad permission, with respect to the photographs, story of me or intellectual property developed while in the Easterseals of the Birmingham Area's program:
I hereby release and discharge Easterseals of the Birmingham Area, from any and all claims and demands arising out of or in connection with the use of photographs, story or intellectual property developed while in Easterseals of the Birmingham Area's Program including any claims from libel.
I have read and explained the foregoing and fully understand the contents thereof.
If the consumer is under 18 years of age, a parent or guardian must sign this form.
Easterseals provides internet access to clients for job search purposes only. The policies listed below are a guide to helo clients determine proper internet and computer systems usage. Easterseals reserves the right to modify policies at any time. If a questionable situation arises, please contact an ESBA Staff Member. Easterseals reserves the right to monitor and record internet usage, electronic mail, and any other computer resource utilization of all clients. Easterseals reserves the right to suspend individual user accounts for violation of usage policies.
I have carefully read Easterseals's Network and Internet Usage Policy. I understand and agree to adhere to the Facility's guidelines. I understand that any questions are to be directed to center staff and any violation of the policies will result in loss of access privileges and disciplinary action.
I hereby authorize Easterseals to obtain Employment Verification on my behalf including but not limited to a paystub and/or an Employment Verification form signed by my employer. I understand that this information is used only for billing and reporting purposes to the referring agency, Alabama Department of Rehabilitation.
In order for an Employment Verification Form to be accurate it must contain the following information:
Easterseals placement staff will need to obtain employment verification twice during the hiring process. Once three days after hire or on the consumer's first "payday," and a second time at the end of the consumer's 90 days follow up process.
With this signature, I agree to do everything in my power to ensure Easterseals gets the appropriate documentation needed.
I hereby authorize disclosure of protected information as follows:
Or Specific Dates of Service:
I understand that:
The following up to date documentation is required for participation in Easterseals of the Birmingham Area's programs. If you are able to upload the documentation now please bring them to your in-person orientation or you may discuss it with the staff member hosting your virtual orientation.
I HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE ALL OF THE ABOVE INFORMATION IS ACCURATE.