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