Release of Consent:
I (Your name) hereby agree to allow Chabot College to disclose my name, mailing address, telephone number, email address, transcript(s), training certificate(s), and any evaluation or feedback provided by a trainer to Alameda County for the purposes of contacting me, training verification, placement, and licensing decisions. This consent is valid from the date of signing through June 30 of the fiscal year in which it is signed.
This consent authorizes the college to provide training information to Alameda County social services department for any applicable training you attend in the current fiscal year unless you request otherwise. Participants are not required to sign this consent. You may withdraw your consent to share this information at any time by mailing a letter to the college’s FKCE Director informing him/her that you wish to withdraw your consent to share information with the county department of social services effective immediately.
The recipient of this contact and training information must note the following: The transmission of the information to others without the separate written consent of the individual is prohibited. The consent notice shall be permanently kept with the record file. The college, the county, and other entities or individuals listed above agree to protect the confidentiality of the data listed on this form and any information transmitted with this form. Copies of this form contain confidential information; they must be secured and discarded by shredding.