Consent for the Release of Confidential Information

  • As we continue to partner together to support your family, we are asking for your written consent for The Factory Ministries and Pequea Valley School District to share applicable and appropriate information regarding your son/daughter.

     

  • My child(ren) and I agree that The Factory Ministries and Pequea Valley School District can share information.

     

    I understand that my information will be shared between the President/CEO of The Factory Ministries and Administration of Pequea Valley School District and shared with other staff members in each organization as deemed appropriate.

     

    The Factory Ministries and the Pequea Valley School District may release my information for service coordination and programming support. Information will be shared on a “need to know” basis only, as applicable to each resource. This release authorizes The Factory Ministries and Pequea Valley School District to disclose information regarding any discipline, grades, attendance, mental illness, developmental disabilities, alcohol and/or drug treatment, physical illness(s) and test results.

     

    This release is valid until one year from today’s date 12/15/2018, at which time it will be renewed as needed. I understand that I can revoke this release in writing at any time; however, I understand that written revocation of this release will not affect disclosures of information that have already been made in reliance on this release, before the time I revoke it.

We appreciate your financial support. Your dollars help sustain our community development efforts.
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