ECC Enrollment Packet Form

Emergency Contact Card
By completing the Emergency Contact Information, you are granting permission for Goodwill Industries of the Columbia to contact the following persons in case of emergency.
Contact #1 Name*
Relationship*
Primary Phone #:*
Alternative Phone #:
Contact #2 Name*
Relationship*
Primary Phone #:*
Alternative Phone #:

Consent For Mutual Exchange of Information
Name*
First Middle Last
Address*
Street Address City State ZIP Code
Phone Number*
Goodwill is seeking your consent to communicate with the following entities regarding items as they relate to your ability to locate, obtain, or maintain employment.

Please INITIAL all that apply.
Current and Potential Employers
Kennewick Community Services
Benton & Franklin Counties Therapeutic Court
Tri City Union Gospel Mission (TCUGM)
Department of Corrections (DOC)
Division of Child Support (DCS)
Mental Health Court
Please INITIAL all methods in which you will allow Goodwill to make contact with the above mentioned agencies.
Verbal
Written
Electronic
Fax
I authorize the mutual exchange of the above listed information or record for the purpose of facilitating my employment goals. It is understood that the information provided above and obtained through this contacted will be treated with the strictest confidence. This release will be in effect for one year from the date signed, unless terminated in writing earlier by myself.
Participant Signature*
Date

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