Release of Information Form (Rebuild)

Be Able

Release of Information Form

Initial only the appropriate boxes:

 Checkboxes 

  • State and Government Agencies on my behalf for the purpose of assisting me with obtaining vital records and identification documents.
  • Emergency Contact Person, Medical Providers i.e. (ER, Rehab, Detox) etc.
  • Parole/Probation Officers, Volunteers, Mentors.
  • Be Able Staff: We enjoy sharing your success stories, also we may need to make contact with other transitional living homes, possible future landlords, etc.
    • I consent to the use of any testimonies or stories I give to Be Able. (Initial) Initials Text field
    • I consent to the use of photos that may be taken at an event or a portrait of yourself to compliment your story. (Initial) Initials Text field

 

OR

 

Checkboxes

 

___________________________________ 

 

Participant Name (Typed):
Please enter your full name, exactly as it is recorded in the application.

First Name:
Client first name

Middle Name:
Client middle name

Last Name:
Client last name

 

Date:
Date

 

Participant Signature:
Signature