Be Able
Release of Information Form
Initial only the appropriate boxes:
- 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.
OR
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Participant Name (Typed):
Please enter your full name, exactly as it is recorded in the application.
First Name:
Middle Name:
Last Name:
Date:
Participant Signature: