Friendly Check-In

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Friendly Check-In

Phone Number

First Name

Last Name

Name to use for me

Age

Pronouns

Residential Address

City/Town

Province

Postal Code

Would you like to receive weekly friendly check-ins from volunteers at Pictou County Rainbow Community?

Yes

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NOTICE OF COLLECTION The personal information on this form will be used for the delivery of The Pictou County Rainbow Community's programs and services. The Pictou County Rainbow Community will not use or disclose personal information beyond the scope defined in the program parameters in this form.RECORD KEEPING The Pictou County Rainbow Community's Programs and Services must keep records on the services provided to you. You have the right to ask for a copy of your records. You will be asked to provide written consent and valid identification upon receipt. Client records are kept for up to seven (7) years. *

I have read and agree with this information

I have read, but do not agree with this information

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