Appendix C "Consent for Release of Information to Agency" - New Brunswick, Canada

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Download Appendix C "Consent for Release of Information to Agency" - New Brunswick, Canada

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PRESCHOOL AUTISM PROGRAM STANDARDS
APPENDIX C – Consent for Release of Information to Agency
I __________________________________________________ (Parent/legal guardian), of the child (full
name) _________________________ date of Birth _______________ consent and authorizes the
Department of Education and Early Childhood Development of the Province of New Brunswick to share /
disclose the following personal information, personal information on health, documents, forms and / or
reports about my child (name of child) with the agency
.
AIS
Please check boxes bellow to receive/share information, documents and reports of:
 Child name
 Date of birth
 Diagnosis confirmation form
 Language of service
 Language of communication with the parents
 Parents address, phone number, and email
I am the parent or legal guardian of the child (full name) ____________________________________ to
which the requested information applies. I declare that I have examined the information on this form,
and accompanying documents, and it is true and correct to the best of my knowledge. I also understand
that I can revoke this consent at any time by providing written notice to the Department of Education
and Early Childhood Development. My signature below indicates my consent.
____________________________________
________________________
Parent/legal guardian signature
Date
____________________________________
________________________
Witness signature
Date
The above information will be used in compliance with the New Brunswick Right to Information and Protection of Privacy Act.
Please send completed and signed forms to
autism.autisme@gnb.ca
or fax to 506-462-2104 or mail to:
Education and Early Childhood Development
Preschool Autism Program
Place 2000, 250 King Street
Fredericton, NB
E3B 9M9
PRESCHOOL AUTISM PROGRAM STANDARDS
APPENDIX C – Consent for Release of Information to Agency
I __________________________________________________ (Parent/legal guardian), of the child (full
name) _________________________ date of Birth _______________ consent and authorizes the
Department of Education and Early Childhood Development of the Province of New Brunswick to share /
disclose the following personal information, personal information on health, documents, forms and / or
reports about my child (name of child) with the agency
.
AIS
Please check boxes bellow to receive/share information, documents and reports of:
 Child name
 Date of birth
 Diagnosis confirmation form
 Language of service
 Language of communication with the parents
 Parents address, phone number, and email
I am the parent or legal guardian of the child (full name) ____________________________________ to
which the requested information applies. I declare that I have examined the information on this form,
and accompanying documents, and it is true and correct to the best of my knowledge. I also understand
that I can revoke this consent at any time by providing written notice to the Department of Education
and Early Childhood Development. My signature below indicates my consent.
____________________________________
________________________
Parent/legal guardian signature
Date
____________________________________
________________________
Witness signature
Date
The above information will be used in compliance with the New Brunswick Right to Information and Protection of Privacy Act.
Please send completed and signed forms to
autism.autisme@gnb.ca
or fax to 506-462-2104 or mail to:
Education and Early Childhood Development
Preschool Autism Program
Place 2000, 250 King Street
Fredericton, NB
E3B 9M9