Authorization for Face-to-Face Telephone Session

Authorization for Face-to-Face Telephone Session
I authorize Jackson-Bibby Awareness Group to conduct DUI Program required Face-to-Face sessions with my counselor over the phone. Jackson-Bibby is not liable for any phone related costs that this may incur on my behalf. I will make myself available at the scheduled time of the call and failure to answer the call and missing the appointment will result in a charged absence. Jackson-Bibby will attempt to call three times and with no answer on the third call,

If participant is unable to attend scheduled phone call, participant is required to call in advance to reschedule or request Leave of Absence with appropriate documentation.
Participant Printed Name*
Phone Number for Telephone Session
Participant Signature*

Clear
Date*

MonthDayYear
Date
Email*
example@example.com
If the participant is not able to sign in person, staff to complete the bottom section:

Participant was not able to sign the form in person prior to their Face-to-Face session.I went over the form with them and I received their verbal authorization.
Staff Printed Name
Staff Signature

Clear
Date*

MonthDayYear
Date
Location*
File Upload

Cancelof
On submitting the form, the form(s) will be emailed directly to Jackson-Bibby.
Should be Empty: