Signature Page
Rev. 12/17/19
I give permission to the EOPS/CARE/Guiding Light program staff to discuss my educational progress on a
“need to know” basis. My academic records and other relevant information will be shared with MSJC
campus based programs and services. In addition, I authorize MSJC campus based programs and services to
discuss my educational progress with EOPS/CARE/Guiding Light on a “need to know” basis.
RULES of CONFIDENTIALITY specify that EOPS/CARE/Guiding Light program staff and its counselor(s) are
mandated by the State under Penal Code Section 11164-11174.3 to report known or suspected abuse to the
proper authorities. Everything you say in EOPS/CARE/Guiding Light will remain confidential except for when
the following items apply, in which case, EOPS/CARE/Guiding Light and its staff are required to report to the
appropriate authorities:
1) Threat of Suicide or Homicide
2) Child, Adult, or Elder Abuse
3) Court Order Subpoena
By signing below, I have read and understand that the EOPS/CARE/Guiding Light program staff will share my
academic records and other relevant information with other MSJC campus based programs and services as
necessary and MSJC campus based programs and services may also share information in support of my academic
success. EOPS/CARE/Guiding Light program staff are required to report known or suspected threats or abuse to
proper authorities immediately.
Print Student Name Student’s Signature Student ID#
EOPS/CARE staff signature: Date: _______________
Public Information Release Form
This form will serve as record of your permission for EOPS/CARE/Guiding Light to use your name, honor roll
statistics, and photographs on public information projects such as EOPS/CARE/Guiding Light brochures,
program newsletters, etc., at the discretion of the EOPS/CARE Director.
This release will be kept in the student’s EOPS/CARE/Guiding Light student file at Mt. San Jacinto College
District until student exits/completes the program. This information is only used for the purposes stated above.
If you have questions about this form or anything mentioned on this form, please contact the
EOPS/CARE/Guiding Light programs at 951-487-3295.
Yes, I give the EOPS/CARE/Guiding Light program permission to use my name and/or pictures for
program promotions.
No, I do not give the EOPS/CARE/Guiding Light program permission to use my name and/or
pictures for program promotions.
________ _______ ____________________
Print Student Name Student Signature Date
EOPS/CARE staff signature: Date: _________________
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