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Case Manager Consent Form

Arizonans For Children, In. (AFC)

Consent for Contact and Release of Information and Liability

NOTE: Consent form must be signed by case manager before child can be enrolled in the AFC life book program and/or matched with a life book volunteer.

I, , the Case Manager for , do hereby grant permission for AFC Life Book Program coordinator to make contact with the above named child and conduct a personal interview for the purposes of applying to be a life book recipient. AFC may also make contact with the above named child for the purposes of screening and interviewing as well as ongoing support of his/her participation in the Life Book program and will be allowed access to the CPS files and school records on the child.

I understand that basic information about the above named child will be anonymously (without names) shared with prospective life book volunteers to aid in determining a suitable match. Once a match is determined, the above named child and caregiver's identity and other relevant information will be shared with the life book volunteer to the extent it aids in facilitating a successful match.

I agree to have the above named child follow all Life Book program guidelines and understand that any violation on the above named child's part may result in suspension and/or termination of the life book relationship.

I do hereby give my consent for the above named child to visit with the AFC staff members and/or volunteers listed below. These scheduled visits will always be supervised by a CPS caregiver. I also give my permission for said staff members and/or volunteers to meet with the child's teacher(s) and/or guidance counselor, and for the release of school/educational, medical, and mental health care records.

Signature of Case Manager:
Printed Name of Case Manager: Date:

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