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Home
About US
Services
Family Support
Services
Resources
Calendar
CIL's in TN
Donate
Contact Us
T.A.R.P. Center for Independent Living
Permission to Release/Receive Information
*
Indicates required field
Name
*
First
Last
I give T.A.R.P. CIL permission to contact
*
for the purpose of
*
Releasing Information
Receiving Information
Information allowed to be shared
*
The only information released or received will be regarding the Independent Living Services the consumer has requested.
The release of this information is in effect until expiration date 1 year after date signed.
I understand that this information will:
Be kept confidential.
Will not be discussed or released to anyone, other than who is listed on the release.
I give permission for TARP Grantors to view my files, if necessary.
Today's Date
*
By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this form
*
I Accept
ILS Signature
*
Date
*
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