Release of Information for Youth Medical Scholars MA Apprenticeship

Purpose of Release The purpose of this release is to allow the exchange of information between the student’s school, the apprenticeship site, and funding sources to ensure the student’s successful participation in the Youth Medical Scholars MA Apprenticeship Program. Information to Be Released:

Academic records (including grades, attendance, and relevant coursework)
Health records and emergency contact information
Behavioral records and disciplinary actions, if applicable
Individual Education Plan (IEP) or 504 Plan, if applicable
Demographic information (including race, ethnicity, gender, and socioeconomic status)
Other relevant information required by our Third Party Administrator, Grant Advocate, Grant Coach, or related authorized entity.

Parties Authorized to Exchange Information:

School: Alain LeRoy Locke College Preparatory Academy
- Contact Person: Dr. Oscar Tovar
- Contact Information: oscar.tovar@animo.org
Apprenticeship Coordinator: Health Care Integrated Services
- Contact Person: Dr. Edna Miller
- Contact Information: hcdd@live.com
Funding Sources: Amity Foundation
- Contact Person: Jesse Barranco
- Contact Information: JBarranco@amityfdn.org

Duration of Release This release of information is valid for the duration of the student’s participation in the Youth Medical Scholars MA Apprenticeship Program, unless revoked in writing by the parent/guardian or student (if the student is 18 years or older).

Student Information

Name *

First

Last

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

School

Grade

Parent/Guardian Information

Parent/Guardian Name *

First

Last

Parent/Guardian Email *

Parent/Guardian Phone

Parent/Guardian Consent

I hereby authorize the following persons and agencies identified above to exchange verbal and/or written information for the purpose of supporting my child's participation in the Youth Medical Scholars MA Apprenticeship Program. I understand that this information will be used to ensure my child’s success and safety in the program and that it will be kept confidential in accordance with applicable laws and regulations. I also understand that this release is necessary for the program to keep being funded. I further understand that information exchanged as a result of this authorization will be exchanged only with those persons in an agency with a legitimate interest in such information. My signature verifies my authorization for information exchange and that I have read this form and/or have had it read to me and explained in language that I can understand.

Parent/Guardian Name *

First

Last

Parent/Guardian Signature

Clear Signature

Date

Student Consent (if 18 years or older)

I hereby authorize the following persons and agencies identified above to exchange verbal and/or written information for the purpose of supporting my participation in the Youth Medical Scholars MA Apprenticeship Program. I understand that this information will be used to ensure my success and safety in the program and that it will be kept confidential in accordance with applicable laws and regulations. I also understand that this release is necessary for the program to keep being funded.

Student Signature

Clear Signature

Date

Revocation of Consent

This consent may be revoked at any time by providing written notice to the apprenticeship coordinator. The revocation will not affect any information that has already been shared under this release prior to the date of revocation.