Participant Consent to Collect Information Form

In order to provide you the best care possible, Reliability Support & Care may collect and store information about you and your support needs in our secure electronic record-keeping system. This information may be used internally within our team, with the intention to provide you with high quality, comprehensive care coordination. Our team will also work closely with other agencies to coordinate the best support for you. Your confidentiality and privacy is important to us, so your informed consent for the sharing of information will be sought and respected in all situations unless:

we are obliged by law to disclose your information regardless of consent or otherwise;
it is unreasonable or impracticable to gain consent or consent has been refused; and the disclosure is reasonably necessary to prevent or lessen a serious threat to the life, health or safety of a person or group of people.

Person Completing this form is: *

Parent/Guardian Full Name *

Participant's First Name: *

Participant's Surname: *

I acknowledge that I am aware of my right to access my personal information. *

I understand that my provider must comply with relevant privacy laws and I will contact Reliability Support & Care immediately if I feel that these laws have been breached. *

I understand why certain information about me may need to be provided to other service providers in order to coordinate the best support for me. *

I acknowledge that I am aware of my right to withdraw my consent at any time. *

Participant's Email: *

Would you prefer to sign or upload a digital signature? *

Please upload your Digital Signature: *

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Date: *