|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|
|_____||Family Learning Partnership
Chugiak Children's Services
Healthy Families Mat-Su
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.