Reading & Math, Inc.

Consent for the Release of Information

Agency Name & Address *

Employment Counselor Name *

Employment Counselor Phone Number

Participant Legal Name *

Participant Email *

Your Employment Counselor and Reading & Math, Inc. are committed to providing you the best quality services. In order to do so, we request to share information regarding your service application, enrollment status, wage detail, and service year experience including training and service attendance.

Check One of the Following *

I AGREE to allow my Employment Counselor and Reading & Math, Inc. staff to share information relative to the status of my application for AmeriCorps service and (if selected) employment/wage detail with Reading & Math, Inc./AmeriCorps.

I DO NOT AGREE to provide consent for my Employment Counselor and Reading & Math, Inc. to share information relative to my application for - and/or employment with - Reading & Math, Inc./AmeriCorps service.

Select Options below

By selecting I Understand, I indicate my understanding that (a) signing this consent and (b) knowledge of my public benefits status in no way impacts my application for AmeriCorps service and/or future employment status with Reading & Math, Inc. *

By selecting I Understand, I indicate my understanding that this information is protected under Minnesota State and/or federal data privacy laws and cannot be disclosed without my written consent unless otherwise provided for under state and/or federal law. *

By selecting I Understand, I indicate my understanding that this information release will remain valid for one year from the date of my signature, unless I request for my Employment Counselor to terminate this consent. *

Participant Name *

Participant Signature * 🛈

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Date * +

Hennepin County Recruiter: Sarah Loquasto (sarah.loquasto@ampact.us; fax 612-871-1777)

Ramsey County Recruiter: Jenny Nyberg (jenny.nyberg@ampact.us; fax 612-871-1777)