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Consent to Communicate

Please check next to all the statements for which you give permission. All or any part of this release may be revoked by the participant at any time by providing written notice to Iris Family Support Center.

I give permission for Iris Family Support Center staff to leave messages on my home/cell voice mail or answering machine.

I give permission for Iris Family Support Center staff to email me at the following email address

I understand that despite allowable contact via Facebook Messenger, Iris Family Support Center staff cannot be followers, friends, or connected with me on social media in any other manner outside of messenger or Iris Family Support Center program specific applications or groups

I give permission for Iris Family Support Center staff to send texts to my cell phone.

I give permissions for Iris Family Support Center staff to send messages via Facebook Messenger on an account I provide

I give permission for technology-based visits in the event that there is a qualifying need and they are approved by Iris Family Support Center and/or the referral agency coordinator.

I do have access to the following:

I agree to:

• Have my camera on during the visit or meeting
• Be in a confidential space during the visit or meeting
• Be stationary during the visit or meeting
• Follow the same guidelines as an in person visit or meeting
• Notify staff if my ability to access any of the services changes

I understand:

• Iris Family Support Center staff will be the host of the visit or meeting
• Iris Family Support Center staff may stop the visit or meeting based on my ability to follow the established guidelines for visits or meetings

Release is valid for no longer than 12 months. Expires on: