Agmt22 Help a Mother Out - Laserfiche WebLink

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REV: 06-22-22 RL IV.Authorization: I hereby authorize the Agency to disclose all of the information contained in this Enrollment Form to: Help a Mother Out 101 Broadway, Suite 250 Oakland, CA 94607 415-938-6667 info@helpamotherout.org The purpose of this authorization is to secure enrollment in the Bay Area Diaper Bank program. I understand that I have the right to revoke this authorization, in writing to the address for Help a Mother Out listed above, at any time, except where uses or disclosures have already been made based upon my original permission. V.Privacy: Help a Mother Out will not share or sell my information to any third party. The information provided herein shall be used by Help a Mother Out exclusively for the internal administration of the Bay Area Diaper Bank, including but not limited to: database management, internal reporting, program evaluation, and feedback. Help a Mother Out will not contact me directly unless it is for program evaluation/feedback purposes. VI.Miscellaneous: I may request a copy of this Enrollment Form. By enrolling in the Bay Area Diaper Bank program at Agency, I hereby agree not to participate any other diaper assistance programs, including at any and all Help a Mother Out partner agencies. I agree not to sell diapers received from the Bay Area Diaper Bank program. I understand that the resale of diapers received from the Bay Area Diaper Bank is strictly prohibited and may result in my immediate termination from the Bay Area Diaper Bank program. I understand that diapers will be provided to me per an agreement between the Agency and Help a Mother Out, and the distribution of diapers are subject to availability and are not guaranteed. Signature of Client: Date: Signature of Agency Representative: ATTY/AGR.2022.161/Help a Mother Out (Help a Mother Out FYE 23 Contract) (Page 8 of 9)