Consent for Release of Information
 

TA Number:____________________

____________________________________ program / school is receiving training and support from the Center for Community Inclusion and Disability Studies (CCIDS).

I/We hereby authorize personnel from CCIDS of the University of Maine and____________________ (person or personnel from program) to exchange information both verbal and written regarding __________________ (child’s name) DOB ______________. This information is to be used for educational purposes for program planning and staff development to support my child in this program.

I/We understand that the child/family records are protected under state and federal confidentiality regulations and cannot be disclosed without my/our written consent. I/We may revoke this consent at any time, and that, in any event, this consent expires automatically as described below.

Date signed__________________________ Consent expires_____________________

____________________________________ _____________________________
Signature of client (parent/guardian)          Relationship to child

____________________________________ _____________________________
Signature of client (parent/guardian)          Relationship to child