University of South Florida
CONSENT/AUTHORIZATION/ RELEASE OF INFORMATION
The signature provided below authorizes __________________________________________to receive/ exchange the below-listed information to or from the listed agencies/person.
___________________________________________________________ ________________________
Job Seeker Name (Printed) Date of Birth
Please list names of relevant agencies/persons. If more space is needed, list on back of form.
Type of information we might need to access: Employment records, Service Provider Records, Medical Records, Social Records, Therapy/Treatment, Educational records
Comments: ______________________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________
All information received will be used for legitimate purposes and confidentiality of all records will be maintained. I understand that my signature allows for release/exchange of information with identified parties that may be of a privileged and confidential nature. This release of information is valid until canceled in writing by the signee.
_________________________________________________________________ ____________________________
Signature of Participant or Guardian Date
____________________________________________ ___________________________________
Printed Name of Participant or Guardian Contact Information (Phone/Email)
Please contact ______________________________ at phone#_____________________ email:_______________________ if you have any questions or concerns regarding this release of information.
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___________________ _______________________
Name Agency/Relationship
____________________________________________
Contact Information: phone, email, etc.
___________________ _______________________
Name Agency/Relationship
____________________________________________
Contact Information: phone, email, etc.
___________________ _______________________
Name Agency/Relationship
____________________________________________
Contact Information: phone, email, etc.
___________________ _______________________
Name Agency/Relationship
____________________________________________
Contact Information: phone, email, etc.
___________________ _______________________
Name Agency/Relationship
____________________________________________
Contact Information: phone, email, etc.
___________________ _______________________
Name Agency/Relationship
____________________________________________
Contact Information: phone, email, etc.
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