GREENE ALLIANCE OF CHURCH/COMMUNITY EFFORTS, INC. (GRACE)

329 Main Street, P.O. Box 513,  Stanardsville, VA  22973

Phone:  434-985-6792  E-mail:  Director@greenealliance.org

I do hereby give my consent to and authorize agent(s) of GRACE to discuss my case and exchange professional, confidential information with all the following agencies or persons as required:

GRACE

Greene County Social Services

Skyline Cap

JABA

Current/Proposed Landlord

Region Ten

Utility Company

Any Church or assisting agency or organization necessary with whom to share or collect information

I understand that any discussion or release of information will be solely for the purpose of coordinating services while I am a client of GRACE. The above names/parties are hereby released from all legal liability that may arise from the release of the information requested. I understand that this consent is subject to revocation by me at any time and, unless an earlier date is specified. that it automatically expires one (1) year after the date below. I understand that if I have knowingly given false or misleading information during this process, I can be denied all services. I also agree to release GRACE and any of its volunteers of any legal liability as a result of any damage, illness, or anything that may result from the goods or services I receive through any GRACE Program. I understand that goods and services are offered on an "as is" basis and with good intentions. Therefore, I will assume all responsibilities for any mishaps. I also understand that without my signed consent, GRACE will not be able to assist.