* = Required Field

I, *, give permission to disclose (share) the following information to the colleges listed below for the purposes of referring to campus-based foster youth support programs (i.e. NextUp, Guardian Scholars). These programs provide supports and resources to students with experience in foster care to help them succeed in college.

I understand that I may revoke this consent at any time by notifying my social worker or ILP Coordinator verbally or in writing. Revoking my consent means that the Los Angeles County Department of Children and Family Services (DCFS) will no longer be allowed to provide my information to the college(s) indicated above. I understand that this does not prevent me from contacting the colleges on my own. I acknowledge that I have read this consent and understand its contents. For youth with open cases, who have attorneys, I understand I may consult with my attorney if I have questions about this form and the sharing of my information.

If not previously revoked, this authorization ends one year from the date of signature. I will receive a copy of this signed authorization if I request it.

(Please use your mouse if you're on a computer, or your hand to sign if you're on a mobile device or tablet.)

(Please use your mouse if you're on a computer, or your hand to sign if you're on a mobile device or tablet.)