I, _______________________a participant in the Family Life Center’s Programs including but not limited to: Outreach, Ho’olanani Shelter, Housing Placement Programs, Emergency Solutions Grant, Rental Assistance Program, Rapid Re-housing Program, Housing First, and Continuum of Care programs, give my permission for Family Life Center to release any information that this agency has regarding my situation, to any agency, organization, or individual that may have need of this information in order to access services, obtain benefits, or advocate on my behalf.
I also give Family Life Center (FLC) my permission to obtain any information from any agency, organization, or individual that this agency may need in order to manage my case. I further understand that my FLC caseworker may collaborate with other agency caseworkers and/or service providers to avoid duplication of services and to increase case management efficiency.
This agreement will automatically expire twelve (12) months after terminating my participation with Family Life Center’s Programs including but not limited to: Outreach, Ho’olanani Shelter, Housing Placement Program, Emergency Solutions Grant, Rental Assistance Program, Rapid Re-Housing, Housing First, and Continuum of Care Programs.
I understand that you can store any information I have given on this form on your computer and this may be seen by any housing association or agency that offers homes to people on the housing needs register.
I certify that this consent has been given freely, knowingly and voluntarily and that I was able to ask questions about this Consent to Release and Obtain Confidential Information form.