Frontline Housing: Operation Housing Release of Information Form

CONSENT FOR RELEASE/EXCHANGE OF CONFIDENTIAL INFORMATION

Frontline Housing Inc. is committed to respecting the privacy of clients participating in the agency's Operation Housing. Personal and financial information should not be disclosed or discussed with anyone without permission or authorization from Frontline Housing's Executive Director, Mary Grace King.

This form allows the Operation Housing to discuss the client via an exchange of information solely for the purposes of the program. This information is meant to allow the Operation Housing to better serve the client participating in the program. The client has the right to revoke consent for release/exchange of privileged information with a written notice submitted to the Operation Housing. The client has the right to revoke consent at any time during the program, with the knowledge that this may affect continued eligibility and the opportunity to receive incentives through the Operation Housing.

Due to the prohibitions of the Federal Rules and Regulations on the Confidentiality of Alcohol and Drug Abuse, Patient Records do not apply to the reporting, under state law, of incidents of suspected child abuse and neglect to the appropriate state or local authorities.

Unless otherwise indicated, this consent for the release/exchange of the information indicated above will remain valid for a period of 12 months after I exit the Operation Housing program. This form requires the client's signature acknowledging you have read the contents of this form and understand the nature of this release.

Regional Commission on Homelessness United Way of Greater Atlanta 100 Edgewood Ave NE Atlanta, GA 30303

Storyteller Release for use of name, personal narrative, likeness and photograph

I hereby grant United Way of Greater Atlanta, Regional Commission on Homelessness and Frontline Housing Inc its respective subsidiaries, affiliates, successors and assigns and other such persons as United Way of Metropolitan Atlanta may designate from time to time, the absolute right and permission to use in perpetuity my name, personal narrative, personal biography, my likeness and photograph(s), in whole or in part, or distorted in character or form, either alone or accompanied by other material, throughout the world, for the purpose of advertising, publicity, education, fund-raising, trade, or any other lawful purpose whatsoever, in any media now known or ever developed.

Ihereby waive all my rights to inspect and approve the finished product, its use or such written or spokencopy as may be used in connection therewith.

I agree that will nothold United Way of Greater Atlanta, the Regional Commission on Homelessness and Frontline Housing Inc or anyone who receives permission form them, responsible for any liability resulting for the use of my name, narrative, biography, likeness and photograph(s) in accordance with the terms hereof and agree to waive and release any such claims, including any distortion, optical illusion or faulty reproduction which may occur in the finished product, which might be challengedas being. a misrepresentation of me, my character or my person, as well as any claim that use of such narrative, biography or photograph constitutes an invasion of privacy.

I am over 18 years of age and have the right to make this agreement.