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Home My WebLink AboutAgreement A-16-555 with WHCCD.pdfAPPROVED BY THE COUNTY OF FRESNO AS TO ITS CAPACITY AS CHIEF LOCAL ELECTED OFFICIAL (CLEO): By:£ :f-~,.-~ Ernest Buddy Mendes , Cha1 an Board of Supervisors BERNICE E. SEIDEL, CLERK Board of Supervisors APPROVED AS TO LEGAL FORM: DANIEL C. CEDERBORG, COUNTY COUNSEL By :~~L~- Date: 21--~ 3 --10 Page 15 of 15 Fresno Regional Workforce Development Board Page 1 of 1 Form# REG-100, revised 060616 1801764v1 / 16988.0001 Universal Voluntary Consent to Exchange Information Name of Client: _________________________________________ WIOA Application #: _______________ Purpose. The Fresno Regional Workforce Development Board (“FRWDB”) needs your permission to share personal information about you with certain organizations in order to best serve you. Voluntary. Your consent is voluntary. If you do not consent, you will still receive Workforce Innovation and Opportunity Act (“WIOA”) services; however, these services will be limited because, among other things, FRWDB will not be able to refer your case to another agency, co-enroll you in additional services, contact an employer to review your performance, or discuss your case with a school or training provider. Scope of Information. This Consent covers all information that is personal to you, including, but not limited to, academic status and performance, employment status, skill assessment information, as well as services provided by other private or government agencies. This Consent does not authorize the exchange of any health (mental or physical) information. Use of Information. By signing this Consent, you allow FRWDB to collect, use, and exchange your personal information with participating partners, employers, contractors, vocational training providers, public and private education institutions, and other entities with which FRWDB interacts or contracts on your behalf. FRW DB will use this information only to support and document your activities and outcomes, to post exit information, and to assess, plan, and facilitate the delivery of services for your benefit. FRWDB may share or receive this information either verbally, in writing, or by computer data transfer. Release. By signing this Consent, you agree to release FRWDB, the City and County of Fresno, and all of their directors, officers, boards, employees, volunteers, agents, participating partners, and contractors from and against any liability and claims rel ated to an unauthorized or accidental release of your personal information. Expiration. This Consent automatically expires 15 months after you exit from your WI OA program. You may also revoke your consent earlier at any time by sending written notice to FRWDB's Quality Manager at the following address: 2125 Kern Street, Suite 208, Fresno, California 93721. Signatures. This Consent is only valid if signed in the presence of an authorized member of your service provider ’s staff. A properly completed and sig ned photocopy of this Consent is as valid as the original. By signing, you acknowledge that you have received a copy of this Consent. Minors. If a client is under 18, this Consent is only valid if signed by the client ’s parent or legal guardian. If you are signing on behalf of a minor child, an authorized staff member of your child ’s service provider will verify your parent or guardian status prior to accepting your signature. Signed: _________________________ Dated: _______ Signed: _________________________ Dated: _______ Client Authorized Staff Signed: _________________________ Dated: _______ Signed: _________________________ Dated: _______ Client's Parent/Legal Guardian Relationship to Client ____________________________ This Consent was translated to ____________________ by _________________________ Dated: _______ Language Translator Agency Summary of Services Provided Non-Medical or Psychiatric Fresno Regional Workforce Development Board Form# REG-101, revised 060616 Date: _____________ Referring Agency: ___________________________________ Participant Name: ___________________________________ Our agency is providing the services identified below, as of the date indicated above, to the named client. Note to Agency: Please place an “X” in the first column if the service listed is being provided by your agency. Please provide comments, if applicable, in the third column. X Type of Service Comments Assessment (Comprehensive) Assessment (Initial) Assessment (Skill Level) Basic Labor Exchange CalFresh CalLearn CalWorks Child Care Classroom Training Community Service Follow-up Services General Relief Homeless Assistance Housing Job Search/Job Placement Medi-Cal Occupational Skills Training On The Job Training Refugee Assistance Transportation Veteran Outreach Vocational Rehabilitation Welfare to Work Work Experience Workshops (specialized) Describe: Other: Other: Other: Workforce Connection – Interest Worksheet Fresno Regional Workforce Development Board Form# REG-104, revised 060616 Name: _________________________________________ Date: _____________________ Badge # ______________ Please check the following services you are interested in: Job Search Assistance Former Military Service Disabilities Assistance Central Valley Professionals Farm Workers Ticket to Success Migrant Seasonal Farm Worker Senior Employment Assistance WIOA Services – CASAS Reading & Math Appraisal + Self Reliance Team (SRT) Interview Youth Services Youth, ages 14-24 Workshops First Things First Career Pillar Interview Mentor Career Development Health Manufacturing Government Infrastructure Housing Assistance Rental Assistance/Section 8 Home Ownership Programs Homeless Assistance Emergency Shelter Temporary Public Assistance CalWORKS Cash Assistance to Families with Children General Relief Food Stamps Medical Services Educational Opportunities GED Community College Adult Basic Education English as a Second Language High School Diploma Other ______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Please present this worksheet to your friendly Customer Service Specialist at the reception desk for further information & direction. Fresno County America’s Job Center of California Level I Referral Form Fresno Regional Workforce Development Board Form# REG-108, rev 060616 Date: Name: Last 4 of SSN: xxx-xx- Phone#: Email: From: WIOA Career Services Providers Other WIOA Providers CLC-P Adult-Dislocated Urban Youth Program (list provider, region, office) WHCCD Adult-Dislocated Rural West Office: Other: Office: Proteus Adult-Dislocated Rural East Office: AJCC Partners EDD, Dept: Fresno County DSS, Dept: SCCCD campus: California Indian Manpower Adult School, Name: AARP Older Americans WHCCD campus: Dept. Of Rehabilitation, Dept: Housing Authority; Dept: Proteus, Program: FEOC-Community Block Grant Dept: Other: , Dept: To: WIOA Career Services Providers Other WIOA Providers CLC-P Adult-Dislocated Urban Youth Program (list provider, region, office) WHCCD Adult-Dislocated Rural West Office: Other: Office: Proteus Adult-Dislocated Rural East Office: AJCC Partners EDD, Dept: Fresno County DSS, Dept: SCCCD campus: California Indian Manpower Adult School, Name: AARP Older Americans WHCCD campus: Dept. Of Rehabilitation, Dept: Housing Authority; Dept: Proteus, Program: FEOC-Community Block Grant Dept: Other: , Dept: Other Community Services (list name of agency and department or location) Agency Name Location Phone # Contact Referral Reason: Fresno County America’s Job Center of California Level II Referral Form Fresno Regional Workforce Development Board Form# REG-109, rev 060616 Date: Name: Last 4 of SSN: xxx-xx- Phone#: Email: From: WIOA Career Services Providers Other WIOA Providers CLC-P Adult-Dislocated Urban Youth Program (list provider, region, office) WHCCD Adult-Dislocated Rural West Office: Other: Office: Proteus Adult-Dislocated Rural East Office: AJCC Partners EDD, Dept: Fresno County DSS, Dept: SCCCD campus: California Indian Manpower Adult School, Name: AARP Older Americans WHCCD campus: Dept. Of Rehabilitation, Dept: Housing Authority; Dept: Proteus, Program: FEOC-Community Block Grant Dept: EDD, Dept: To: WIOA Career Services Providers Other WIOA Providers CLC-P Adult-Dislocated Urban Youth Program (list provider, region, office) WHCCD Adult-Dislocated Rural West Office: Other: Office: Proteus Adult-Dislocated Rural East Office: AJCC Partners EDD, Dept: Fresno County DSS, Dept: SCCCD campus: California Indian Manpower Adult School, Name: AARP Older Americans WHCCD campus: Dept. Of Rehabilitation, Dept: Housing Authority; Dept: Proteus, Program: FEOC-Community Block Grant Dept: Other: , Dept: Other Community Services (list name of agency and department or location) Agency Name Location Phone # Contact Referral Reason: Signed Release of information on file Y N Employment Plan: Y N Being Developed N/A Assessment Completed: Y N List assessment type: Results: Orientation: Y N Appointment Time: Date: Appointment with: Phone#: Address: I understand this referral is being made to better assist me in my employment goals. Client Signature_____________________________ Date: __________________ Outcome: