Consent to Disclose Personal Information

CONSENT TO DISCLOSE PERSONAL INFORMATION

Your written consent authorizes Fresh Start Support Services to disclose your personal information to the individual you have designated on this form.

If you have any questions regarding the disclosure of your personal information, please contact our Privacy Officer, at sfier@fsms.ca.

authorize,

, a staff at Fresh Start Support Services, to disclose the following information:

my application to Fresh Start Support Services' programming, including my application to Campus Housing;

my personal contact information, like my phone number and email;

my medical information (please provide more information below);

updates regarding supports received from Fresh Start Support Services, like system navigation and parenting supports;

other:

Please provide details of information that can be shared:

with,

working at,

Date Signed

Date Consent Expires

I understand that I can withdraw consent at any time.

I understand that this consent is voluntary and I do not have to consent to any information being shared that I don't want to have shared.

I understand that this consent will expire one year from the date that I signed.

Your Signature

Thanks for submitting!