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Consent for Disclosure of Personal Information to a Third Party

 

Personal Information: I understand that my personal information may include my date of birth, contact information, records of meetings with me and/or my family, the services I or my child received, the programs I or my child attended, details of physical and mental health, medical, psychological or psychiatric reports, school information, financial information, employment history, allegations or findings of child maltreatment, court documentation, police interventions, criminal history, the information that  I reported/provided contained in the record,  my or my child’s views or opinions, the views and opinions of others about me or my child and information about my or my child’s race, ancestry, place of origin, colour, ethnic origin, citizenship, family diversity, disability, creed, religion, age, sex, sexual orientation, gender identity, gender expression, cultural or linguistic needs, marital or family status. 



Your Personal Information

Please fill in your own personal information below.

*To ensure the most accurate search of our records, please list the names and birth dates of your parents and siblings.

*Previous addresses that may coincide with the records you are requesting.

Disclosure of personal information

I want Peel CAS to send my personal information to:

Instructions


How would you like us to send the information?

Please note that if you select email, you acknowledge the potential privacy risks including but not limited to:

 - Email may not be secure.  While we try to protect our emails, we cannot guarantee the security and confidentiality of any email you send to or receive from us.  As the message leaves Peel CAS, it is sent across the internet and it could be intercepted and read by anyone.

 - Email is easy to forge, easy to forward (sometimes accidentally and too many people) and may exist forever.

We recommend you give us a personal email address that only you read.  We recommend that you use an email address and system that is password protected.  If you give us a family email address or share your email address with anyone else, you should know that other people might also receive or read emails we send to you.  If you use a work email address, your employer may have a right to archive and look at emails sent from their systems.  We recommend you avoid using a work email address.

Peel CAS is not responsible for information loss due to technical failures.

If you choose to receive your records by email you agree that Peel CAS shall not be responsible for any personal injury including death, or privacy breach (outside the control of Peel CAS) or other damages that result from your choice to receive your records by email.  You release and hold harmless Peel CAS from any liability relating to the email communication. 

 

Terms of acceptance and signature

By signing this form, I hereby consent to a search being conducted of the records of Children's Aid Societies in Ontario and the examination and disclosure of any information in the possession of or under the control of a Children's Aid Society in Ontario, regarding myself. I understand that some Ontario Children's Aid Societies are using CPIN (Child Protection Information Network) as their documentation system. I understand that when an agency using CPIN searches for my record, it will find all records of my involvement with all Ontario Children's Aid Societies also using CPIN. I further understand that when an agency uses CPIN, now or in the future, my information will be entered in the Provincial Child Protection Information Network. 

 

I, the requester warrant the truthfulness of the information provided in this form.

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.*

Two copies of identification are required to complete this form (one of which should be a photo ID). Please upload them here.

Please check all the information and make sure all the supporting documents are attached before submitting this form. Alternatively, email all documentation to disclosure@peelcas.org.

Please note: Peel CAS will not sell your email address or disclose your personal information to third parties without your consent.