Release of Information Consent Form

Dear Volunteers,

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Subject *

Name *

Member ID *

Email *

Please specify the type(s) of information you authorize to be released: *

Volunteer Employment Information

Volunteer Activities

Supervisors' Recommendations & Comments

I hereby authorize the release of protected information or other confidential information from volunteer [me] to Burmese Orchid, as specified below. This consent is voluntary and can be revoked at any time. *

Right to Revoke

I understand that I have the right to revoke this authorization at any time by providing written notice to Burmese Orchid. The revocation will not affect any information already released prior to the receipt of the written revocation.

Re-disclosure

I understand that once information is disclosed pursuant to this authorization, it may be re-disclosed by Burmese Orchid and may no longer be protected by privacy regulations.

Signatures

I have read and understand the terms of this authorization and voluntarily consent digitally to the release of information as described above.

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Release of Information Consent Form

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