Confidentiality of release policy: Please read the following information carefully, before checking box below. Please let us know if you have any questions. I give my permission to RALLY project to share pertinent confidential information given on my application and in my case file, give authority, as deemed necessary, with churches, organizations, utility companies, pharmacies, state and/or federal agencies, and/or medical care institutions, in order for RALLY project to provide assistance that I request. This release of information will remain in effect unless terminated in writing by me. All the information given is true and correct to the best of my knowledge. At any time, I can revoke this consent to share information. *
