Dufferin-Peel Catholic District School Board
4 0 M a t h e s o n B o u l e v a r d We s t , M i s s i s s a u g a , O n t a r i o L 5 R 1 C 5 • T e l : ( 9 0 5 ) 8 9 0 - 1 2 2 1
CONSENT TO DISCLOSE STUDENT'S PERSONAL INFORMATION -
SCHOOL TO PARISH
TO: _______________________________________________ SCHOOL YEAR: _________
(School)
I/We, Parent(s)/Guardian(s) of:
_____________________________________________________________________________
(Student)
hereby give my Consent to provide the following personal information to:
_____________________________________________________________________________
(Parish)
My child's name, school and grade; my child's address/telephone number;
My name, address and telephone number.
Other personal information being requested:
_____________________________________________________________________________
I understand that the purpose of this disclosure is to assist the Parish with this year's
preparation and planning of the Sacrament of Communion / Reconciliation /
Confirmation, and for no other purpose.
______________________________________________________
(Name of Parent/Guardian)
_____________________________________________________
(Signature of Parent/Guardian)
__________________
(Date)
I DO NOT GIVE MY CONSENT TO DISCLOSE ANY PERSONAL INFORMATION OF
MY CHILD OR ANY OF MY PERSONAL INFORMATION TO THE ABOVE PARISH.
______________________________________________________
(Name of Parent/Guardian)
______________________________________________________
(Signature of Parent/Guardian)
__________________
(Date)
(June 2007)