P:352-877-4666 W: www.megasocialenterprise.org Fax:1-800-314-8404 E: [email protected]
AUTHORIZATION TO RELEASE INFORMATION FORM
MEGA SOCIAL ENTERPRISE
Vocational Services
Student’s Name:
Student’s Social Security Number (or Last 4 digits):
Date of Birth:
I hereby authorize Mega Social Enterprise Inc & Mega Enrichment
Academy (dba for Ella and Rosa Safe Haven and Care Inc.) to (check one):
Staff: Lydia Bogans, Mary Dornes, Kimberly Jones
__ __ obtain from the following
_____ release to the following
Agency Name:
and/or
School Board & School Name:
School Address:
The following documents/information from the records pertaining to services received or that will be received
Date of Service:
The documents to be released are described or listed as:
IEP plan, 504 plan, other relevant school documentation and information in regards to the scope of Transition Youth
Services, STAR Program, and/or Vocational Rehabilitation Services.
The records are required for the specific purpose of:
To communicate with staff, coordinate services, and to compile & submit training records, required documentation,
and invoicing to Department of Education/Division of Vocational Rehabilitation and school or agency listed above.
I understand that my authorization will remain effective from the date of my signature until a year out from date or
_____________(date) and that the information will be handled confidentially in compliance with all applicable
federal laws. I understand that I may see the information that is to be sent, and that I may revoke the authorization
at any time by written, dated communication. I have read and understand the nature of this release.
___________________________________________________
Signature of Student
___________________________________________________
Signature of Parent or Guardian (if applicable)
___________________________________________________
Witness
____________________
Date
____________________
Date
____________________
Date