Employment Services Referral Form

Referral Information

Consent for Release of Information

In an effort to coordinate services, I hereby authorize the above-named service provider organizations to share and/or release any applicable information pertaining to my participation in services.

I acknowledge that the referring service provider may be notified once I have made contact with the referred service organization. I understand that I may, in writing, change or cancel this authorization at any time, except for such action as has already been taken.

As it pertains to Referrals from Ontario Works, MFIPPA applies:

I acknowledge that my personal information may be shared with various program participants as contemplated by s.14(1)(a) of the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, CHAPTER m.56; I understand that the treatment, storage and handling of my personal information is governed by the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, CHAPTER m.56