General Release of Information Form

Choose your YMCA of Niagara Employment Services location:

The Participant gives permission to the YMCA of Niagara Employment and Immigrant Services staff to provide information, verbally and/or written, to: *

The Participant also understands that all information provided and shared will be kept completely confidential and not provided to any other source or party without their direct approval and permission.

Is the participant over 16 years of age? *

Yes
No

By entering my name below, I acknowledge that my Service Provider has explained its use and disclosure of my personal information for its purpose.

Participant's name: *

First

Last

Participant's consent: *

I agree
I do not agree

Parent/guardian's name: *

First

Last

If participant is under 16 years of age

Parent/guardian's consent: *

I agree
I do not agree

If participant is under 16 years of age

Date: *

E-mail: *

This consent is valid for 1 year after program closure date.