Youth Community Services Form

WWWWIW is required to report to all its funders;

• My “basic” personal information
• The services I obtained during my visit(s)
• My overall satisfaction with the services I’ve received

My information will also be used for reasons including, btu not limited to; research, follow up, referrals, and as a means for the funders to administer and finance further services.

The WWWWIW staffs agree to protect my information by using and disclosing my information only as permitted by me in this Authorization and as directed by provincial and federal law.

I do not have to sign this Authorization. If I decide not to sign the Authorization, I will not be allowed to participate in the releasing of my information. I also acknowledge that by not signing this Authorization, I cannot participate in any services provided by WWWWIW.

At any given time, I can revoke this authorization by submitting a written letter to: 1368 Ouellette Ave., Suite 100, Windsor, ON N8X 1J9. I will be given a signed copy of this form upon my request.

I authorize the use of my information as described above.