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Confidentiality Releases

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* 1. Name

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* 2. Your driver's license number? and state.

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* 3. Permission to use your photo on our webpage and in promotional materials.

Webpage

Brochures

Emails

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* 4. OK to release your info to ministerial agencies.

Food distribution

Churches

Counselors

State agencies

More

Other (please specify)

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* 5. I acknowledge that I've been told of the faith based curriculum for this program...

Yes

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* 6. I will participate in fundraising activities if there happens to be one while I'm enrolled.

Yes

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* 7. Voluntarily turn off cell phone

Yes

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* 8. I acknowledge and agree that Confidentiality is ensured except:

Information released when required by the court

Threat of suicide or homicide

Abuse required to be reported by law

Other legal accessory crimes required to be reported by law

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* 9. I will not make a claim against, sue, attach the property of, or prosecute any action against any Sponsoring Organizations of the Mosaic Center. Sponsoring Organizations include but are not limited to any participating church, association, or organization and their affiliates; and any of these entities' employees, agents, servants, officers, directors, shareholders, successors, or assigns.

Yes