I grant permission to Saahas for Cause organization, the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium. I hereby release Saahas for Cause and its legal representatives from all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during an interview or guest lecture, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation.

I acknowledge that I am over the age of 18.

I understand that for the purpose of supervision, monitoring, and coordinating services, the information I disclose may be communicated to the organization staff and/or supervising clinicians on an as-needed basis. This information will be considered confidential and held to the standards recommended by law.

Some functions within these programs or services are provided by service providers external to the department(s). However, I understand that no information may be revealed to anyone outside the organization without my written permission except where disclosure is required by law, including:

(1) If threaten suicide or physical harm to myself;
(2) if I threaten homicide or physical harm to another person, including property; and/or
(3) if there is a reasonable suspicion of child abuse or elder/dependent adult abuse.

I understand that, at any time, in case of an emergency or crisis, I should call 911.

Saahas for Cause is committed to providing an environment that is free from discrimination and unlawful harassment. In the event that you wish to report any discrimination you faced based on the basis of race; color; religion; sex (including pregnancy, childbirth, and related medical conditions, transgender status, and gender identity); national origin (including LEP); age; disability; political affiliation or belief; or, on the basis of citizenship status, you can report to Saahas for Cause's management at info@saahasforcause.org.

IMPORTANT NOTICE:

If you are a client receiving services from Saahas for Cause, including survivors of domestic violence, you are not required to participate in any services in order to access emergency shelter or other resources. All services and resources offered by Saahas for Cause are voluntary. No conditions or requirements may be placed on clients to participate in any service or program, regardless of its significance.

I acknowledge that I have read and understood the above information regarding the collection, use, and disclosure of my personal information.