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2 <br />III. Acknowledgement and Agreement: <br /> <br />By your signature below, you are certifying that: <br /> <br />• You have received a copy of the documents listed above in section II; <br /> <br />• You will abide by the County and your employing Participating Agency’s <br />policies and procedures concerning information sharing and confidentiality when <br />participating as a member of an AB 210 MDT; <br /> <br />• You agree that you will only share/disclose information that you reasonably <br />believe is generally relevant to the identification, assessment, and linkage of <br />homeless adults and families to housing and supportive services; <br /> <br />• You understand that no confidential information or writings shall be disclosed to <br />persons who are not members of the AB 210 MDT, except to the extent required <br />or permitted under applicable law; <br /> <br />• You agree that information and/or records you obtain as an AB 210 MDT <br />member will be maintained in a manner that ensures the maximum protection of <br />privacy and confidentiality rights; and <br />• You understand that any violation of this Participation and Confidentiality <br />Statement is grounds for immediate suspension or revocation of your current and <br />future authorization to disclose or receive confidential information as a member <br />of any AB 210 MDT and may result in additional disciplinary measures. <br /> <br />Name: <br /> <br />Department/Agency Name: <br /> <br />Job Title: <br /> <br />Email: <br /> <br />Telephone: <br /> <br /> <br />Signature: Date: <br /> <br />Please email the completed document to: HSA Center on Homelessness, <br />HSA_Homeless_Programs@smcgov.org <br /> <br />8.H. - Page 21 of 31 <br />178