Authorization to Share Job Corps Student Records for Program Eligibility Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Section 1—Purpose of this FormThe purpose of this Form is to obtain your permission for the U.S. Department of Labor and its contractors or grantees (DOL) to share information contained in your Job Corps applicant and/or student file (Student Information) with Workforce System Partners to assist you in identifying job placement, training, and educational services. Job Corps applicant and student records are protected by the Privacy Act, 5 USC 552a, and can only be disclosed in limited circumstances pursuant to the Privacy Act. If you grant DOL permission to disclose your Student Information, DOL may disclose the following; general biographical information including contact information, veteran status, social security number, and student ID number, information related to your income or the income of your family, information related to educational attainment, information related to career technical training, driver’s license attainment, diplomas, transcripts, resumes, and information relating to recreational activities such as student leadership positions. Job Corps will not disclose protected health information related to health care received while enrolled in Job Corps. Your Student Information may be provided to the following Workforce System Partners; One Stop Centers, recipients of grants awarded under the Workforce Innovation and Opportunity Act, Public Law Number 113-128, July 22, 2014, or sponsors of Apprenticeship Programs registered under the National Apprenticeship Act 50 Stat. 664, Chapter 663. If you are an unemancipated minor, your parent or guardian must grant permission on your behalf. You are not required to grant permission to disclose your Student Information to participate in the Job Corps program, and whether you grant or deny permission does not affect your eligibility for the Job Corps program. Section 2—Identity of Applicant or StudentStudent/Applicant Name: *FirstLastDate of Birth: *Phone Number: *Email *Name of Parent or Guardian (if student/applicant is a minor):FirstLastPhone Number of Parent or Guardian (if student/applicant is a minor):Email of parent or guardian (if applicant/student is a minor): *Section 3—Consent to Disclose Student InformationOption 1: For adult students and emancipated minors.I, (enter Student/Applicant Name below) *FirstLastgrant permission for DOL to disclose my Student Information to Workforce System Partners as described in this Authorization onEnter Today's Date or is Student Student/Applicant Signature Clear Signature Use a mouse, finger or trackpad on a laptop to sign your name above. Option 2: For unemancipated minor students.I, (enter the name of parent or guardian below) *FirstLastgrant permission for DOL to disclose Student Information of (enter the name of the Student/Applicant below) *FirstLastfor whom I am the parent or guardian, to Workforce System Partners as described above in this Authorization onEnter Today's DateParent/Guardian Signature Clear Signature Use a mouse, finger or trackpad on a laptop to sign your name above. Submit
