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Release for Information Authorization

Release for Information Authorization

Please complete the following form to authorization the release of information.

Notice to Candidate

Information gained in the course of the Process of Evaluation for ministry belongs to the Annual Conference. The examiner is an agent of the Annual Conference. Further, your relationship with the examiner is not a treatment relationship and as such, the Annual Conference, not the examiner, controls whether you, as a candidate will have access to this information. Some Annual Conferences will provide access prior to the submission of the Assessment by the examiner; some after submission to the Annual Conference; and some, at no time. You are encouraged to clarify this issue with your Annual Conference.

1. I understand that the Process of Evaluation for ministry includes a psychological assessment. I understand that at the conclusion of the Assessment a written report is to be prepared, or has been prepared, which will contain conclusions, opinions, observations, or recommendations by a mental health professional conducting the examination.

2. I hereby grant release of access to the assessment report, subject to the terms herein specified.

3. I authorize the mental health professionals involved in the assessment to disclose the written assessment report to designated representatives of the Annual Conference, including the district committee on ministry, and the board of ordained ministry of the Annual Conference. I authorize the mental health professionals involved in the assessment to discuss the written assessment report with the designated representatives of the Annual Conference as enumerated above.

4. I understand that the Annual Conference will have the right to control the use and disclosure of information regarding the assessment both during consideration of my application, with designated persons listed below, on a need to know basis. Should I terminate the candidacy process, the information will be retained in accordance with the personnel policies of the Annual Conference.

6. Upon release by the examiner, all records will be maintained pursuant to policies of the Annual Conference on record retention, and policies designed to protect the privacy of candidates from unnecessary disclosure of otherwise personal information. However, unless otherwise specified, the raw data from any psychological tests or inventories which I have completed remains the sole property of the examiner and only his or her opinion as expressed in the assessment report will be released. The examiner will maintain the raw data or any other material about me as confidential mental health records, pursuant to law of the jurisdiction in which the examination is conducted.

I understand that, in addition to the Annual Conferences access to this information for its selection decisions, the General Board of Higher Education and Ministry may also use this information as part of ongoing research. I understand that my confidentiality will be protected in such research.

7. I agree that if any portion of this Authorization for Release of Information is found by a court to be unenforceable for any reason, the remainder of this consent and authorization for release shall remain valid and in full force and effect.

8. I have carefully read this release form and fully understand its contents. I sign it of my own free will. I understand that I may consult with an attorney of my choice before signing this document. I acknowledge that I have had the opportunity to ask questions concerning the contents of this form and any such questions have been answered to my satisfaction. Nonetheless, in agreeing to sign this document, I have not relied upon any statements or explanations made by the Annual Conference or its ministers, officers, employees, volunteers, agents or legal representatives, any personnel and entities involved in conducting the assessment and their officers, directors, employees, volunteers, agents, heirs, administrators, successors, assigns or legal representatives.


Dakotas Annual Conference of The United Methodist Church 605.996.6552 1331 University Ave. Mitchell SD 57301-0460 US 43.69689310 -98.03291320 122 W. Franklin Avenue Ste 400 Minneapolis MN 55404 US 0.00000000 0.00000000 1331 W University Ave Mitchell SD 57301 US 0.00000000 0.00000000 1331 University Ave Mitchell SD 57301 US 0.00000000 0.00000000