Consent Agreement

By checking this box, I hereby authorize the Safer Foundation ("Safer") and its Affiliates, including its subsidiaries Reconstruction Technology Partners (RTP), Safer Focus Housing, Safer Counseling and Wellness Center, and Pivotal Staffing, individually and collectively (“Safer Foundation Parties”). I consent and authorize the Safer Foundation Parties and their respective employees, agents and/or representatives to share, disclose and release information regarding my background including, but not limited to, my contact information, self-disclosed criminal convictions, my educational background and my employment history ("Background Information"**) between and amongst the Safer Foundation Parties for the purpose of registration as a client with Safer and for future service coordination. The Safer Foundation Parties will take reasonable efforts to prevent the disclosure of the Background Information received by the Safer Foundation Parties to unauthorized parties. I understand I have the right to revoke this authorization in writing at any time by sending written notification to the Director or program manager responsible for my services. I further understand that my right to services and the quality of services provided to me is not contingent upon my completion with this consent. I lastly acknowledge that certain programs or services at Safer Foundation may require further disclosures, acknowledgement, or consents depending on governing regulations and laws