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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