2016-2017 Informed Consent For Disclosure Of Personal Information
St. Joseph's College collects and protects personal information under the authority of the Alberta Freedom of Information and Protection of Privacy Act for the purpose of operating the programs and services of the college.

If you require the disclosure of your personal information to another person (parents, roommates), designated agent or agency, legal counsel or other purposes, please complete the following informed consent document as required under the Act.

I voluntarily authorize
Individual/Office/Program
Your answer
to disclose
State precise personal information (such as your address, name, email address etc.), with a date range if applicable.
Your answer
originally collected for
State Purpose for the original collection of information
Required
releasing to
Identify specific individual, organization or recipient category.
Your answer
for the purpose of
State specific purpose of this information release
Your answer
Full Name:
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Student I.D. #:
Your answer
Email Address
Your answer
Date:
MM
/
DD
/
YYYY
Electronic Signature:
Consents may be revoked at any time by so indicating in writing to the Residence Office at St. Joseph's College.
Your answer
NOTE:
Protection of Privacy – This personal information requested on this form is collected under the authority of Section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act. It will be used for the purposes of managing the consent for disclosure of personal information process. Questions concerning the collection, use and disposal of this information should be directed to the Director of Residence at sjcres@ualberta.ca.

This information will be retained and disposed in accordance with approved records retention and disposal schedules of the college.

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