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: December 9, 2024
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