770 – 1st Street SE
Medicine Hat, AB
T1A 0B4

Phone: 403 – 529 – 4733
Fax: 403 – 529 – 4734
Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

CONSENT TO RELEASE YOUTH DOCUMENT

All sections of the form below must be filled out. Please be specific with the document you are requesting release of (i.e. resume, cover letter, safety tickets, etc.). All requests must be followed by a legible signature, printed name, and date. If any part of this form is incomplete, YouthWORKS! will be unable to release your document(s).
*This consent is valid only on the date submitted.

I, ___________________________, give permission to ____________________________________ to

access and receive ______ copies of my ______________________________________________.

 ___________________________________  ____________________________________
 Youth Signature    Date Submitted

___________________________________
Youths Name Printed

Due to confidentiality requirements, YouthWORKS! is required to abide by strict standards in accordance with the Government of Alberta in keeping youths’ records and personal information private and confidential.  All registered youth have been informed of confidentiality standards that staff are required to adhere to in accordance to youths’ information.

For Office Use
Date Received Staff Name