Consent to Communicate using Email or Texting

Required fields are marked with asterisks (*)

Consent to Communicate using Email or Texting

I/We,

consent to communication by email or text messaging (“texting”) in order to share personal information between myself and an authorized representative of Region of Waterloo Community Services (“Region”).

Disclaimer – Please Read Carefully

Email and texting is not a secure mode of communication. It is not recommended by the Region or by provincial privacy guidelines.

Sharing personal information using email and texting has risks that you should be aware of, such as:

Messages can be accidentally sent to the wrong person by mistyping an email address or a phone number
Messages may be read on cell phones and laptops, which are vulnerable to being stolen or lost
Messages can be forwarded to others or changed without the original sender’s knowledge or permission
Email and texting programs are vulnerable to hacking, spam emails, viruses, or to someone trying to get access to your personal information

However, at your request, we can email or text you in certain circumstances, such as when:

You have identified a need for emailing or texting to:Schedule, re-schedule, cancel or confirm an appointment
Send information related to program eligibility or benefits (such as a change of address, phone number, paystub or other personal documents)

We are trying to contact you and:

We can’t reach you any other way
We need to reach you quickly and waiting could have a negative impact

By signing this form you are confirming that you have read and understood the information provided, and you are aware that:

The Region does not accept legal liability for any of the risks mentioned that may arise from email or texting with you;

Messages you send to Region staff using email or texting will be deleted once the important information has been added to your record. We will not collect any more information than is required to serve you;

All emails and texting from Region-owned phones and computers are monitored according to Region guidelines; and

You consent to the Region communicating with you using the email address and phone numbers you provide for the purposes outlined above.

I/We have read (or had read to me/us) and understand the information and consent set out above.

Was verbal consent given from the client?

Yes

Verbal consent was given from the client on this date:

Signature of Applicant:

Clear

Date:

Signature (Spouse/Co-Applicant/Children over 18):

Clear

Date:

Signature(Substitute Decision Maker):

Clear

Date:

Email Address:

Phone Number (for Texting):

In which city will you be attending this program?

Kitchener

Cambridge

Waterloo

Notice with Respect to the Collection of Personal Information

(Municipal Freedom of Information and Protection of Privacy Act)

This information is collected under the legal authority of the Ontario Disability Support Program Act, 1997, or the Ontario Works Act, 1997, or the Housing Services Act, 2011, or Child Care and Early Years Act, 2014, or the Ministry of Community and Social Services Act, for the purpose of providing social assistance programs.

For more information please speak with your worker.

Approved May 2, 2018 by CSD DLT