A Statement of Rights and Responsibilities



Release of Information

Name: ____________________________________________________

Activity: __________________________________________________

Release valid only for the following dates:

From: ________________ To: ____________________

I, _____________________ give permission for _______________________, and other TILRC staff to receive and release information from the above activity (ies) to/from:

List All:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

It is understood that this release only applies to the above activities and dates.

Signed: __________________________________ Date: _______________

Signed: __________________________________ Date: _______________

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