Participant Personal Data Form

Personal Information

  Private Ins

Participant/Guardian Agreement

I certify that all the information provided herein is true and complete to the best of my knowledge. I know that any misrepresentation herein may lead to rejection of my application. I understand that I will be receiving/participating in Families First Services to learn valuable knowledge, skills, and behaviors that strengthen relationships, improves communication, problem-solving, decision-making, and life coping skills.

Confidentiality and Consent to Release

Confidentiality and Consent to Release: I authorize The Family Resource Center to release documents or information over a 6-month timeframe starting from the date of my signature. Confidentiality standards will be observed according to those required by HIPAA. I authorize release to the following:
Electronic Signature: Please accept my name and last four digits of my Social Security Number typed by me in the Participant/Guardian box as my confirming that the above information entered is mine and is correct.