Family Promise of the Jersey Shore
I ______________________ authorize Family Promise of the Jersey Shore (FPJS) to contact agencies and individuals for information about me or my family for the purpose of case management and referral.
This authorization includes all agencies and individuals with whom I have worked or may work through referrals by FPJS. This authorization will be considered a mutual release.
The release of content includes but is not limited to information regarding entitlements, job performance, financial/credit background, mental health history, legal history, and substance abuse history.
The release is limited to the time I am a guest of the FPJS and expires upon my departure from the program.
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Name of Guest (print) Guest Signature Date
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Name of Guest (print) Guest Signature Date
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Staff (print) Staff Signature Date