Easterseals Adult Program

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)

• Two forms of identification required for I-9
• Up to date resume for job searching (Placement and center staff can assist with this)
• Commitment to follow-up on job leads provided and regular (weekly) contact with placement staff
• Let placement specialist staff know if a job lead results in an interview or job offer
• Employment readiness classes are included in the services sponsored by you Alabama Department of Rehabilitation Vocation Counselor and attendance is expected
• Keep Easterseals staff updated on address and phone number changes
• Let Easterseals staff know of anything that would keep you from taking a job
• Be active in your job search and let the placement staff know of any job leads that you have found or applications you have completed
• Let Easterseals center staff know of any concerns or problems with your service
• Follow-up services are provided after a job is obtained for at least 90 days
• Understand that the plan is to find a job in the vocational area listed as your goal by your Alabama Department of Rehabilitation Vocation Counselor.

Easterseals Staff

• Make sure that job referrals are appropriate
• Develop, review and change individualized Employment Services Plan with Consumer
• Make sure services provided are timely, to include but not limited to returning calls, scheduled contacts, job referrals to the consumer
• See consumer as an active member of the team
• To be honest with, respectful of and available to the consumer
• Maintain confidentiality of information related to the consumer
• Make available information related to the qualifications of Center Staff

The following signatures indicate that the program expectation agreement has been reviewed with and accepted by the consumer and staff.

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.

• Email and file transfers are to be for job search use only by authorized users
• Use of another client's accounts or access to their personal files without their consent is strictly prohibited
• SHaring your user ID with any other person is prohibited. In the result that you do share your user ID with another person, you will be solely responsible for any actions that the other person appropriates
• Any unauthorized, deliberate action which damages or disrupts a computing system, alters its normal performance, or causes it to malfunction is a violation regardless of system location or time duration
• Forgery (or attempt forgery) of electronic mail messages is prohibited
• Attempts at sending unsolicited junk mail, "for-profit" messages, or chain letters are prohibited
• Use of systems and/or networks in attempts to gain unauthorized access to remote systems is prohibited
• The use of systems and networks to connect to our systems in evasion of the physical limitations of the remote system/local is prohibited.
• The decryption of system or user passwords is prohibited.
• The copying of system files is prohibited.
• The copying of copyrighted material, such as third-party software, without the express written permission of the owner or the proper license, is prohibited.
• Intentional attempts to "crash" network systems or programs are punishable disciplinary offenses
• Use of systems to get o social networks such as Facebook and Twitter is prohibited
• Any attempt to secure a higher level of privilege on network systems is a punishable disciplinary offense
• Confidential information is not to be transmitted over the internet without proper encryption
• All downloaded files or applications are to be scanned for viruses before being saved on the center's network
• Software installation by users on any network drive is strictly prohibited
• Disruptive behavior such as introducing viruses or other disruptive/destruction program, or intentionally destroying or modifying files on the network is strictly prohibited
• Any personal use of the network for commercial or illegal activity is strictly prohibited
• Game playing is strictly prohibited
• Security on the internet is a high priority. If you feel you can identify a security problem on the internet, you must notify ESBA's network Administrator. Do not demonstrate the problem to other users
• When dealing with email attachments assume that all attachments have a virus and treat them with extreme caution. Do not detach or launch any attachments with the following file extensions: .exe, .com, .bat, .vbs, .cmd, .asp, and .scr. The only exception to this is when the file was sent to you by a member of the Easterseals staff. Do not open email nor detach or launch email attachments sent by non-trusted sources. Suspicious emails should be deleted immediately. If you receive a Microsoft Word or Excel file as an email attachment, always choose "disable macros" when prompted.

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:

• Employer Name
• Supervisor Information
• Start Date
• Wage
• Weekly Work Hours
• Business Address
• Job Title
• Supervisor
• Benefits
• Other relevant 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:

1. This information is protected under federal law.
2. I may refuse to sign this authorization.
3. I have the right to revoke this authorization in writing, but if I do, it will not have any effect to the extent that Easterseals has taken into action in reliance on it.
4. This authorization will expire on the date listed above. If I fail to specify an expiration date or event this authorization will expire in five years.
5. Your information will not be released to any other individual or agency except to the one listed above without prior written permission by you, or if a minor the parent or legal guradian.
6. By signing below, I recognize that the protected information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient of this disclosure and may no longer be protected under federal law.
7. Treatment or payment will not be based on the signing of this authorization
8. Photocopies of this release form will be considered as original. 

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.