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Consent Form for CAFN Education Staff

Consent Form for CAFN Education Staff

The purpose of this form is to allow you to give us your consent (or not) to release personal and confidential material related to your childrens.
Please check in the options below the right ones for you.

I hereby give consent to CAFN education staff to provide support and programs for all of my child(ren) within any of the Yukon schools.

Yes

No

I hereby give consent to CAFN education staff to communicate private information to its affiliates to ensure eligibility for scholarships, awards nominations, partnerships (i.e. Dakwakada Development Corporation, CA Trust, etc.).

Yes

No

I hereby give consent to CAFN education staff to communicate with teachers, school administration, other service providers and other CAFN staff (Employment and Training Officer; Post-Secondary Officer; CAFN Case Manager) in matters related to my child (ren) within any of the Yukon schools.

Yes

No

I provide consent for the release of my child(ren)’s educational records to enable the Yukon Department of Education to provide data to the Champagne and Aishihik First Nations Government, as follows:

Release of attendance records (may be used to support regular attendance at school).

Yes

No

Release of individualized reports from teachers, counsellors and administrators. This includes IEPs, behavioral plans, students support plans, school incident reports, etc.

Yes

No

Release of reports cards and transcripts.

Yes

No

Advocate on behalf of my child (ren) and myself. This includes attending school meetings, sitting in on disciplinary meetings, meeting with other agencies (your ESW will sit in on your behalf, take notes and relay information back to you).

Yes

No

You can list any other subjects/materials you would like your ESW to have access to:

All the information provided is kept confidential and access to these documents is restricted to CAFN Education Department Director and staff, on an as needed basis.

This consent form is valid for (please choose one of the options below):

1 year from the submit date

From the submit date until my child(ren) graduates

If at any time I wish to withdraw this consent, I will submit a letter to the Director of Education or the Education Support Worker indicating my withdrawal and for which student(s).

How many Children are you applying for?

Children 1 Data

Full Name including middle & last name

First

Additional Name (nick name)

First

Date of Birth

DD slash MM slash YYYY

School and Grade

First

Children 2 Data

Full Name including middle & last name

First

Additional Name (nick name)

First

Date of Birth

DD slash MM slash YYYY

School and Grade

First

Children 3 Data

Full Name including middle & last name

First

Additional Name (nick name)

First

Date of Birth

DD slash MM slash YYYY

School and Grade

First

Children 4 Data

Full Name including middle & last name

First

Additional Name (nick name)

First

Date of Birth

DD slash MM slash YYYY

School and Grade

First

Children 5 Data

Full Name including middle & last name

First

Additional Name (nick name)

First

Date of Birth

DD slash MM slash YYYY

School and Grade

First

Print Parent/Guardian Name:

First Last

Signature of Parent/Guardian:

Date

MM slash DD slash YYYY

Δ

HAINES JUNCTION OFFICE

#1 Allen Place, P.O. Box 5310
Haines Junction, YT Y0B 1L0
867-634-4200

WHITEHORSE OFFICE

304 Jarvis Street
Whitehorse, YT Y1A 2H2
867-456-6888

COMMUNITY BUILDINGS

Takhini Hall 867-667-6701
Da Ku Store 867-634-3307
Youth Center 867-634-2012
Mun Kų 867-634-7001
Champagne Hall 867-634-2336
Klukshu Hall 867-634-2342

contactus@cafn.ca

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