I understand fully that this authorizes release of personal records, not limited to employment, education, or housing information, and that it will be released only to the above-named organization or person for the purposes listed above.
This release will expire twelve (12) months from the date of signature. I may revoke this authorization at any time by notifying the organization or person in writing of my intent to revoke. However, such revocation will have no effect on any records previously shared or services delivered.