READ FIRST: Before you decide whether or not to let DAIP share some of your confidential information with another agency or person, an advocate DAIP will discuss with you all alternatives and any potential risks and benefits that could result from sharing your confidential information. If you decide you want DAIP to release some of your confidential information, you can use this form to choose what is shared, how it's shared, with whom, and for how long.
I allow DAIP to share the following specific information with:
Who I want to have my information:
What information about me will be shared:
To receive credit for women's non-violence group
Why I want information shared: (purpose)
Women's Non-Violence Group Information (attendance and participation)
Please Note: there is a risk that a limited release of information can potentially open up access by others to all of your confidential information held by DAIP.
I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time orally or in writing.