Riverside County Department of Public Social Services
CONSENT FOR RELEASE OF INFORMATION
NAME: (Last, First, Middle)
SOCIAL SECURITY NUMBER: DATE OF BIRTH:
MAIDEN OR OTHER NAME USED (Last, First, Middle)
I, the undersigned, consent to, and request, the Department of Public Social Services to release information
regarding myself to
for use in education/vocational
(NAME OF INSTITUTION)
planning and for evaluating my participation in CalWORKs Welfare to Work activity. I authorize the release
of information which may include one or more of the following:
! Name ! Social Security Number ! Date of Birth
! Address ! Telephone Number ! Other: ______________________
I, the undersigned, consent to, and request
to release information
(NAME OF INSTITUTION)
regarding myself consistent with the Federal Family Educational Rights and Privacy Act of 1974, or other
laws, regulations, or policies to the Department of Public Social Services for use in participation evaluation
for CalWORKs GAIN. I authorize the release of information which may include one or more of the following:
! Education and occupational assessment and evaluation ! Financial Aid information
! Educational records, including progress made ! Other
! Current employment status ________________________
All information will be kept confidential and maintained as part of my records with the CalWORKs Office at
the college and/or the CalWORKs GAIN Office. Additionally, all information will be used exclusively in the
administration or delivery of services.
The release shall remain in effect during my enrollment or until revoked in writing by the undersigned.
SIGNATURE OF STUDENT
DATE
SIGNATURE OF PARENT OR GUARDIAN (Required of students under 18 years of age.) DATE
I have read and understand the conditions and purposes of this consent form. At this time, I DO NOT authorize any
sharing of information by the institution I am attending. I understand that I will not be able to participate in programs and
services offered through the CalWORKs office at the college as a result of this decision.
SIGNATURE OF STUDENT
DATE
SIGNATURE OF PARENT OR GUARDIAN (Required of students under 18 years of age.) DATE
RVSD 3021 (7/04) Education Consent
