HRC, Inc.

Work Services
Fax (907) 376-0157 Phone (907) 352-2559

Letter of Consent

I ______________________________, give my permission to the Work Services Programs to provide information to and obtain information from the agency/agencies checked below:
_____	Adult Basic Education	_____	Division of Vocational Rahabilitation
_____	Dept. of Labor/ Employment Services	_____	Division of Public Assistance
_____	WIA (formerly JTPA)	_____	Mat-Su School District—Dzuuggi
_____	Life Quest	_____	Mat-Su College
_____	Family Learning Partnership Chugiak Children's Services Healthy Families Mat-Su	_____	Multi-Rush Center
_____	Mat-Su Recovery	_____	other _________________
It is my understanding that only information that is relevant to my work and educational goals will be exchanged. THIS RELEASE OF INFORMATION WILL EXPIRE WITHOUT EXPRESSED REVOCATION UPON COMPLETION OF MY TRAINING OR SPECIFIED DATE __________________. This consent is subject to revocation (in writing) at any time except that action has been taken thereon.

Parent/Guardian Signature Date		Customer's Signature Date
*Witness Signature Date		Customer's Social Security Number
*Witness Signature Date		Customer's Date of Birth Month/Day/Year
>If a customer is a minor, signature of parent or guardian is required. *If unable to write his or her name, the customer should enter "X" or another mark. Signatures of two witnesses are required.