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REQUEST FORM

Please fill out the contact information below with the information for the person we should contact


The 4 The Love Foundation serves Thurston County residents only

(Unless extenuating circumstances such as being unhoused and staying in Thurston County for emergency shelter)

Our Outreach Specialist will review this request and contact you at the phone # you provided above. Please note that our foundation website has a link to our ROI if applicable.

Release of

Information

Only needed if we are sharing your information with an outside group, organization, or individual

Please Read Carefully Before Proceeding

Before allowing 4 The Love Foundation to share your confidential information, their advocate will discuss the options, risks, and benefits with you. If you agree, use this form to specify what information is shared, how, with whom, and for how long.

Method of Sharing Information (check all that apply):

Acknowledgments:

This release expires on:

Date and time
:

By signing this release, I acknowledge its validity and understand that I can revoke my consent at any time, either verbally or in writing.

Today's Date
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