Release of Information To Another Agency / Facility
I ______________________________ hereby authorize Enfield Adult Education to release information regarding my progress , course grades , or reference information in the Certified Nurses Aide Training Program at Enfield Adult Education , to the following :
Name of Agency / Facility ______________________________________________________ Address ______________________________________________________________________ City __________________________________________ State ________ Zip ________________
_____ Please check here if you ' d like to have Enfield Adult Education release this information to any agency / facility that requests it from us & sign your consent below .
Student Name ________________________________________________________________ Address ______________________________________________________________________ City __________________________________________ State _______ Zip _________________
Signature ________________________________________________ Date ______________
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