Consent Form

                        CONSENT TO BE INCLUDED IN THE
                             KinKonnect DIRECTORY

  _______________________________________, consents to having 
            (Name of Agency or Organization)           
information concerning the organization's services included in the  KinKonnect Directory. 

We understand that the KinKonnect  Directory will be available on the KinKonnect Web Site

and in print version.  We agree to provide information to KinKonnect and to periodically

update the information provided.  We understand that we may withdraw our name from the

Directory, at any time by contacting KinKonnect.

 We understand that inclusion in the KinKonnect Directory is not an endorsement of our

services by KinKonnect, Children’s Aid and Family Services Inc., or the Division of Youth

and Family Services.

 We certify that the information provided to KinKonnect is accurate. 

_________________________________                             _______________________
Name                                                                                      Agency or Organization

__________________________________                            _______________________              
Signature                                                                                  Date          

                                                                                               _______________________                                          
                                                                                                Phone Number