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ENROLLMENT FOR SERVICES & RELEASE OF CONFIDENTIAL INFORMATION FOR THE IN*SOURCE YOUNG ADULT PROGRAM

The signatures below confirm the following: 

• Permission &/or intent for participant named to participate in the IN*SOURCE Young Adult Programs including Pre-Employment Transition Services (Pre-ETS). 

• Reciprocal release of information between IN*SOURCE (the Indiana Resource Center for Families with Special Needs), the participant’s school, Vocational Rehabilitation, and other Local Pre-ETS providers if applicable. 

• If the participant is in high school and 18 or over, the participant consents to release information to the parent/guardian. Specific information to be released includes all documents, materials an&/or other information required for the participation in, provision of, or resulting from the IN*SOURCE Young Adult Programs including but not limited to: disability documentation including IEP, 504 Plan, health plan, other disability documentation, i.e., school evaluation, parent or physician documentation, student work, interests, resources, education and transition related strengths and needs. 

If applicable, this release also gives permission for IN*SOURCE to obtain information from Indiana Vocational Rehabilitation on the case status with Vocational Rehabilitation during the time the student is enrolled in pre-ETS and for one-year post-exit from pre-ETS. 

I understand that I may revoke the consent provided in this form at any time, by providing IN*SOURCE with a signed and dated written notice. This consent shall remain valid for so long as the student is a recipient of IN*SOURCE Young Adult services or until the student exits school. I hereby release IN*SOURCE and any of its directors, officers and employees from all claims, actions, demands or judgments created by or arising out of said release of information. 

Today's Date: April 19, 2024

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*

Phone*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*

Phone*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*

Phone*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*

Phone*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*

Phone*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*

Phone*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*

Phone*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*

Phone*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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