Grand River Post Secondary
Education Office
P.O. Box 339, Ohsweken, ON, N0A 1M0
Tel. (519) 445-2219 Toll Free 1 (877) 837-5180
Fax
(519) 445-4296
CONSENT TO REQUEST AND RELEASE INFORMATION
|
| A. Personal Information (Please print or write
legibly) |
| __________________________________________________________________________________ |
| First Name |
Middle Name |
Last Name |
| __________________________________________________________________________________ |
| Home Address |
|
Telephone Number |
| __________________________________________________________________________________ |
| Academic Address (if
different
from home)
|
Telephone Number |
| __________________________________________________________________________________ |
| Date of Birth |
Academic Student Number |
Social Insurance Number |
| __________________________________________________________________________________ |
Education
Institution
|
Address of Educational Institution
|
| B. Consent to Request Information
|
I,________________________________,
provide my consent, as may be required by statute, to allow the Grand
River Post Secondary Education Office to request copies of information
from employers; all sources of income; educational and employment and
training institution (s); federal, provincial and Six Nations
government offices/agencies. This consent allows the Grand
River Post Secondary Education Office to verify information to determine
my eligibility to receive Education Assistance
|
| C. Consent to Release Information
|
| I,________________________________,
provide my consent, as may be required by statute, to allow the
Grand River Post Secondary Education Office to release information
and provide copies of documentation to educational and employment
and training institution (s) and federal, provincial and Six Nations
government offices/agencies. This consent allows the Grand
River Post Secondary Education Office to provide information so that
my eligibility for other assistance (including employment) may be
determined and to confirm any assistance received through the Grand
River Post Secondary Education Office. |
| o
VOLUNTARY CONSENT
|
|
By checking this box, I
provide my voluntary consent to the release of the following
personal information to Grand River Employment and Training
(GREAT) for the purpose obtaining career related employment.
Personal information is defined as: name, address, telephone
number, e-mail address, name of post secondary institution
enrolled in, length of program and graduation year. In
giving this consent I understand that GREAT shall not
release my information until I provide written permission. |
|
| D. SIGNATURES
|
| This signed consent is
valid until _________________________, 20 _____. |
| Dated this ___________ day
of ______________________, 20 _________. |
| _____________________________ |
|
____________________________
|
| Signature |
|
Signature of Witness
|
| Forms of Photo
Identification: |
Verified by: |
| ( ) Driver's
Licence___ |
( ) Student Card____ |
( ) Indian Status Card
____ |
( ) Other
(specify)____
|
| WHITE
COPY: FILE
|
YELLOW
COPY: INSTITUTION
|
PINK
COPY: STUDENT
|
AP1003G.08
|
|