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Authorization to Obtain/Release Information - Declaration

By completing this form, I hereby authorize March of Dimes Canada to obtain and/or release personal information to be used only as needed to complete program demographics and analytics, and for my successful completion of the program.

I consent for March of Dimes Canada to obtain and/or release the following information from/to service providers and/or family:

Program information including progress and employment goals and outcomes
Employment and skills profile for the purpose of facilitating mentorship matches

I consent for March of Dimes Canada to release the following information from/to funders:

Anonymous demographic information for the purpose of program analytics

Acknowledgement*

I acknowledge that March of Dimes Canada will not share any personal information containing my name, address, and contact information with a third party.

Effective Period of Consent – 2 years *program analytics are required for up to 1 year from start date

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Authorization to Obtain/Release Information - Declaration

By completing this form, I hereby authorize March of Dimes Canada to obtain and/or release personal information to be used only as needed to complete program demographics and analytics, and for my successful completion of the program.

I consent for March of Dimes Canada to obtain and/or release the following information from/to service providers and/or family:

I consent for March of Dimes Canada to release the following information from/to funders:

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