By filling out this Assistance Request, I am authorizing SCC to share my information with the BringJesus network, which is a group of churches and individuals who provide help to the needy in the name of Jesus Christ. The information will not be shared outside of the network except to obey the law, including mandated reporter laws.
I also authorize SCC and the BringJesus network to contact any of the persons listed on this form to verify and discuss the information I provided, including any information about my spouse and minor children who are named on this form, and including but not limited to medical records, psycho-social records, test or examination results, counseling and therapy history, residence and employment history, background clearances, references, child care providers, public or private agency social workers, governmental entities, probation/parole officers, and all other information and persons with information relevant to my request. I agree to waive any confidentiality rights (for myself, my spouse, and my children) to the extent that sharing of the information is reasonably necessary to ensure the appropriate, safe, and fair provision of services according to my request.
I release all members of the BringJesus network from any liability related to or arising out of the services requested or provided, including emotional distress, and excepting willful and intentional bodily harm. I agree that any disputes related to or arising out of the services requested or provided must be resolved by binding arbitration according to the rules and procedures of the American Arbitration Assocation, and that each party shall bear its own attorney fees and costs.
