2006-2007
Vision Home and Community Program
Release of Information
For the purpose of:
q
Documenting the Vision
HCP program: writers,
photographers, grants, the Vision HCP portfolio, the Vision HCP documentary
video, etc.
and/or
q
Networking with Vision
HCP participants who want to meet with me or get a reference for Educators,
programs, etc.
I am willing to: (please
check all appropriate boxes below)
q
Talk to potential
Vision participants who would like more information.
q
Talk to mentors or
Educators.
q
Give information to
other Vision schools with programs to offer.
q
Talk to members of the
community interested in the program.
*Pertinent information may
include the information listed below.
Please check each box below indicating which information you are
authorizing the Vision HCP to release for the purposes checked above.
q
My name
q
Phone Number
q
Mailing Address
q
E-mail Address
q
Samples of my work
RCs will keep information
received from a Learner or family confidential unless: (1) it is information
the RC is required by law to share, or (2) the RC feels it is in the best
interest of the Learner or family for the RC to seek counsel and share needed
information with other Vision HCP staff or RCs in order to gain their advice
and support. All such parties will
keep any information shared confidential.
__________________________________
Learner Name
_________________________________________ _________________________
Parent/Guardian
Signature Date