Authorization to Release Information (Release from Liability and Waiver)
To any law enforcement agencies, civll records authorities and Borland Free Clinic: I authorize you to release to the Borland Free Clinic any and all information and civil or criminal records naming me, including all entries where I am named as being arrested, as a suspect, as being citied for any crime, violation, infraction or offense, or as otherwise involved or named in any report by any member agency of your organization.
The information that I have provided is accurate to the best of my knowledge and may be verified, if necessary by contacting persons or organizations named in this application, or by contacting any person or organization that may have information concerning me, or by conducting a criminal background check. I hereby release and agree to hold harmless from liabilityany person or organization that provides information. I also agree to hold harmless Borland Free Clinic and employees and volunteers thereof.