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Consent to Release Information 

I herby give permission to Family Promise of Colorado Springs to share the following:
With the followng local agencies:

The purpose for such disclosure is to further collaboration and coordination of services in compliance with Family Promise of Colorado Springs' housing programs and Community Cares programs. 

I understand I may revoke this consent at any time and that in any event; this consent expires automatically as described below or annually. Specification of the date, event, or condition upon which this consent expires is one year after date signed. 

I hereby release the provider from any liability, which may result from furnishing the information as authorized in the release. Regulations prohibit disclosure of this information without my specific written consent. If information released to the above-mentioned agencies, beyond the above mentioned parameters by the identified agency, I will not hold the above mentioned agencies liable for the acquisition of this additional information. If the consent is revoked, redisclosure of my case management records may not done without further written consent. A photocopy of this authorization is to be considered as valid as the original. 

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