Consent for Release of Confidential Information
I consent to and authorize the release of my confidential information as listed below to Mt. San Antonio College; to provide and coordinate services, payments, and benefits or for other purposes authorized by law. I further grant permission to Mt. San Antonio College and the following agencies and their consultants to use my confidential information and disclose it to each other for these same purposes: the Foundation for California Community Colleges, the California Department of Social Services, the California Community College Chancellor’s Office, the County of Los Angeles Department of Public Social Services, the California Employment Development Department, and the U.S. Department of Agriculture Food and Nutrition Service.
The confidential information I hereby release is limited to the following:
College records, such as enrollment and financial aid records, course completion records, academic progress records, educational placement tests, and educational plans
Fresh Success records, such as intake forms, participation records, career assessment results, and supportive services records
CalFresh and CalFresh Employment & Training records
Employment information as reported by my employers, including wages by quarter
This authorization shall remain in effect as long as the records are needed for the reasons listed in the first paragraph of this form. I understand that I may withdraw this consent at any time in writing, but that will not affect any information already shared. A copy of this form is valid to give my permission to release confidential information under the terms of this consent.
I hereby release and hold harmless all of the persons/organizations designated in this document from any and all liability and claims of any kind, related to the release, sharing, and use of information, as described in the foregoing, provided by any/all of the persons and organizations indicated. This release form has been read and reviewed with me and I understand its content. I understand that disclosing my social security number is voluntary but will be important in helping locate my employment records.