SHE IS US UNITED INC. Community Health Data Consent Form
Review the consent options, confirm your understanding, and sign to record your permission.
Introduction
Do you want your responses to remain anonymous?
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Yes, keep my responses anonymous.
No, my responses can be associated with me.
Do you give permission for your data to be shared with partner organizations?
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Yes, I give permission.
No, do not share my data.
Participant Rights
Please confirm all statements below to continue:
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I understand my data will not be sold.
I can withdraw my participation at any time.
I agree to the terms stated above.
Signature Page
Full Name
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First Name
Last Name
Date
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Month
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Day
Year
Date
City and Zip code
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Electronic Signature
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Are you 18 years of age or older?
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Yes, I am 18 or older.
No, I am under 18.
If under 18 years old, Please list a parent or guardian name and phone number for emergency purposes
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First and Last Name
Phone number
A parent or guardian must sign this form. Please contact info@sheisusunited.org for assistance.
Submit Consent
Submit Consent
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