CSInformationAuthorization

Authorization for Release of Information

Consent for participating adults ages 18 or older must fill out this Authorization for Release of Information.
Student Email*
example@example.com
I, Student First Name* Student Last Name* hereby consent to and authorize College Steps at:
Program Location*
Release and Receive Information to and from:*

College/UniversityHigh School/DistrictDepartment of Disability & Aging ServicesDepartment of Vocational Rehabilitation (VR)Parent/FamilyDo Not Include AnyoneOther
If applicable, list College/University name
If applicable, list High School name
If applicable, list Department of Disability & Aging Services office/contact
If applicable, list Department of Vocational Rehabilitation (VR) office/contact
List Parent/Family member name
List Parent/Family member name
List any other contact name
To this end, released and received information includes (remove check boxes for any items you do not wish to be shared):

Mental health records and informationMedical health records and informationEducational records and informationFinancial Aid informationRecords from Department of Vocational Rehabilitation (VR)Records from Department of Disability and Aging Services
My signature below indicates that I have read and understood the foregoing and I consent to my information being shared by and with College Steps for purposes of services delivered to me by College Steps. I understand that consent to share my information is voluntary and my refusal to grant consent will have no effect on any CS services to which I may be entitled. I further understand that I may at any time exercise the right to rescind my consent. If I want to revoke this right, I will submit written documentation to the College Steps Program Coordinator on campus immediately.
Signature of Individual*

Clear
Signature Name*

First NameLast Name
Date of Signature

MonthDayYear
Date
I currently have a Legal Guardian (includes parent, guardian or shared living provider if the student has guardianship or is not yet 18)*

YesNo
My Legal Guardian Has to Sign Separately

YesNo
Legal Guardian Email*
example@example.com
Signature of Legal Guardian*

Clear
Legal Guardian Name

First NameLast Name
Date of Signature

MonthDayYear
Date
Should be Empty:

Authorization for Release of Information