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Universal Release Information
Universal Release Information
admin
2021-03-11T20:25:39+00:00
Universal Release Information
Name
*
First
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
I Authorize:
*
First
Last
To release information contained in the records of:
*
To the Individual and/or Organization:
*
Apatisiwin Program (Swampy Cree word meaning “employment, training, and jobs”)
AADW Program (Aboriginal Alcohol & Drug Worker)
ACMHW Program (Aboriginal Community Mental Health Worker)
ACWP Program (Aboriginal Court Worker)
AHA program (Aboriginal Housing Advocate)
AHBHC Program (0-6 yrs
AHOW Program (Aboriginal Health Outreach Worker)
AHWC Program (Aboriginal Health & Wellness)
AKWE:GO Program (7-12 yrs
FWW Program (Family Wellness Worker)
ICYMHA Program (Up to 18 yrs
IFAW Program (Indigenous Family Access Worker)
KANP Program (Kizhaay Anishinaabe Niin Program)
Literacy - Latiy^te’hta?as (19+) Adult Literacy Program
LLC Program (Life Long Care)
UAHL-HK Program (0-18 yrs
UAHLP (Urban Aboriginal Healthy Living Program)
Wasa-Nabin Program (13-18 yrs
CRC Program (Cultural Resources Coordinator)
CAIFC Events (Community Events)
Reciprocal Release
*
Yes
No
Name of Person/Organization to whom information will be released:
*
Specific type of information to be released:
*
The purpose and need for such information:
*
This release expires on:
*
Date Format: MM slash DD slash YYYY
Client or Guardian's Signature
*
Date
*
Date Format: MM slash DD slash YYYY
Witness Signature
*
Date
*
Date Format: MM slash DD slash YYYY
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