To release or obtain information about my participation in programs funded by ARPA Community Resilience Program. Specific information will include my name, address, phone number and other personal details as well as details I provide through program intake, surveys, or assessments.
This information may be used for the purpose of following my program participation and Sonoma County Black Forum to improve services for me. helping Sonoma County Black Forum I understand that is entering data that can be used by the Sonoma County Human Services Department (HSD) and software contractors for the purpose of supporting data collection and to help HSD better understand the needs of groups of clients. In addition, I give The County and their contracted staff permission to use my data to conduct a program evaluation of how ARPA funding may lead to improved well- being outcomes for children and families. I understand that any report created will only reveal data about groups served, and that my personal identity will not be shared.
This Release of Information is valid until June 30, 2026. This Release of Information expires automatically on the date noted here unless I ask you to cancel it in writing sooner.
I understand that: I have a right to receive a copy of this authorization and have been offered a copy. I have the right to tell you to stop sharing my information. I can tell you, or I can writea letter to:
Sonoma County Privacy Officer: 1450 Neotomas Ave, Santa Rosa, CA, 95405 or by e-mail at DHS-Privacy&Security@Sonoma-County.org or call (707) 565-5703 If I tell you to stop sharing my information, you will stop on the day I tell you to stop, but it will not affect information you already shared. I understand I don't have to sign this form and my information won't be shared if I don't sign it. The County won't deny me treatment, enrollment, or eligibility for benefits if I don't sign this form; however, some services and treatment won't happen if I don't allow my information to be shared. Information that the agencies share with each other may then be shared by the person who gets the information, except for certain federally protected drug and alcohol records. I understand that some of the information that is shared may no longer be protected by privacy laws; for example, if I allow information to be shared with a family member.
By my signature below, I affirm that I have read this release or it has been read to me, and I understand its content.