STATE OF CALIFORNIA	DEPARTMENT OF REHABILITATION

CONSENT TO RELEASE NON-MEDICAL

PERSONAL/CONFIDENTIAL INFORMATION

DR 264 (REGS/Rev. 01/90)	See Reverse for Important Notices

De favor de leer el otro lado de esta pagina

To

William S. Hart -TPP	Applicant/Client's Full Name (Print)

Address

21380 Centre Pointe Parkway

Santa Clarita, CA 91350-2948	Social Security Number

XXX -XX-	Date of Birth

Address

Name/Title of Person/Firm

William S. Hart- TPP Staffs	Other Identifying Name

Other Identifying Number

I hereby consent to and authorize the Department of Rehabilitation to:

obtain from you the following information:

release to you the following information:

Description of information to be released:

1) Individual Plan for Employment (IPE)

2) Individualized Educational Plan (IEP) and Educational Assessments

3) TPP Monthly Progress Reports regarding Employment Services, Work Experience, and TPP School

services.

4) School Academic Progress ( transcripts and other school progress)

5) Vocational information: Resumes, Applications, Assessments and Emloyment Information

6) Referral information (address, phone, email, and other required form info)

7)Communication (electronic, written,in-person, or telephone) related to vocational services.

I understand that I have the right to

receive a copy of this signed authorization	I understand that this consent shall be valid for a period not to exceed 30 days, unless otherwise specified*, from the date this consent is signed.
*Specified date, if other than 30 days.

(Stamp, print or type)

From /	Send Information to:	Applicant/Client's Signature

	Date

Department of Rehabilitation

23838 Valencial Blvd., # 303

Santa Clarita, CA 91355

Parent or Guardian's Signature (required for minor)


If unable to write his/her name, the applicant/client should enter an "X" or other mark, signatures of two witnesses are required.
Witnesses' Signature


Telephone

Rehabilitation Counselor

Witnesses' Signature


DISTRIBUTION:	Copy 1 (Original) - Addressee	Copy 2 - Case File	Copy 3 - Applicant/Client

STATE OF CALIFORNIA	DEPARTMENT OF REHABILITATION

CONSENT TO RELEASE NON-MEDICAL

PERSONAL/CONFIDENTIAL INFORMATION

DR 264 (REGS/Rev. 01/90) REVERSE

NOTIFICATION OF THE INFORMATION PRACTICES ACT OF 1977

If information is being OBTAINED from you, you should be aware that under State law and departmental regulations, all information you supply to the Department of Rehabilitation is maintained in files that are subject to inspection by the applicant/client.

If information is being RELEASED to you, you should be aware that this is confidential information from the records of the California Department of Rehabilitation. State law and departmental regulations prohibit you from making any further disclosure of this information without informed, written consent of the person to whom this information pertains.

AVISO DEL LAS REGLAS TOCANTE EL ACTO DE 1977 DE INFORMACION

Si usted va a DAR información, debe de saber que esta es información confidencial contenida dentro de los archivos del Departamento de Rehabilitación estatal. Leyes estatales y regulaciones departamentales le prohiben a usted hacer cualquier otra revelación de esta información sin el concentimiento informado y escrito de la persona de quien pertenece esta información.

Cuando usted nos entrega informacion debe de saber que bajo la leyes estatales y regulaciones departamentales, toda la información que usted le de al Departamento de Rehabilitacion se mantiene en archivos que pueden ser inspeccionados por el solicitante/cliente.

STATEMENT OF NONDISCRIMINATION

The Department of Rehabilitation affirmatively supports all federal and state civil rights laws and will not knowingly do business with any agency or entity which discriminates on the basis of ethnic group identification, national origin, race, color, creed, religion, sex, age, sexual orientation, physical or mental disability, medical condition, marital status or ancestry.

DECLARACION CONTRA LA DISCRIMINATION

El Departamento de Rehabilitación declara que está de acuerdo con las leyes federales y estatales y no establecerá negocios con agencias o organizaciónes si se da cuenta que la discriminación existe contra personas por razon de su grupo etnico, raza, color, origen nacional, religion, sexo, credo, edad, orientación sexual, incapacidad física o mental, condición medica, estado civil o ascendencia.

STATE OF CALIFORNIA

Steve Icamen

2013-10-09

skatz

Department of Rehabilitation