Copy of Niisaachewan Anishinaabe Nation Jordan Principle Consent Form

Consent Information

The information will be appropriately safeguarded, only used to apply for funding/ group applications for the child/ren of ages 0-18 (until they officially turn 18) specific and will not be disclosed for any other purposes. I understand the purpose for disclosing this personal and/ or educational information to the person noted above. I understand that there may be a limited usage of photos and videos. I understand that I can refuse to sign this consent form.

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* 1. I consent to release my children/ youth personal information for support towards group application process through Jordan Principle in accessing health, social and educational products, services and support they may need.

Yes

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* 2. Have consent on file for the year 2021-22 or until such time the child/youth is no longer in the primary care of the parent

Yes

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* 3. Permission to use photos or videos and / or the first name of my child/ren for the celebratory and promotional purposes.

Yes

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* 4. Please list each child: Full name & Date of Birth

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* 5. Contact information

Parent Name

Address

City/Town

Province

Postal Code

Email Address

Phone Number