Information Sharing Policy

I understand that the Children'sCouncil of Watauga County, Inc. (hereinafter "Children's Council") coordinates with a variety of community agencies to access different services and benefits on my behalf. Each of these agencies may require certain information to provide their services. By signing this form, I am authorizing the Children's Council to share, provide, and exchange any and all information I provide to it with other agencies for the purpose of coordinating benefits and/or services. I am also providing my express permission to the agencies that receive my information to use such information to coordinate benefits and/or services on my behalf.

The authorization provided herein is valid for 365 days from the date written below or until I am no longer receiving benefits and services from The Children's Council and/or any agency that receives my information pursuant to this authorization, whichever occurs earlier. I understand that I may withdraw this authorization at any time by informing the Children's Council in writing. I understand that I may request a summary of the information that the Children's Council has shared related to me or my family, the purpose for which it was shared, the date(s) such information was shared, and the recipients of such information. I acknowledge that if I do not wish to grant authorization to share information with other community agencies, I will be responsible for providing the information required by each referral agency.

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