RETAF Application

Release of Information and Waiver of Liability

THIS FORM MUST BE SIGNED BY AL PARTICIPANTS. IF PARTICIPANT IS UNDER 18 YEARS OF AGE, FORM MUST BE SIGNED BY MINOR AND HIS/HER PARENT/GUARDIAN.

IN CONSIDERATION of the undersigned Participant being permitted to voluntarily participate in the on-on-one community resource counseling provided by Park Central Development the participant hereby:

1. ACKNOWLEDGES, agrees and represents that Participant will receive one-on-one community resource counseling with either a staff member or supervised intern at Park Central Development. Participant understands that this is a voluntary service the participant is choosing to engage in. Participant further acknowledges and agrees that community resource counseling appointments will include an initial intake survey along with an assessment of needs and a creation of an action plan. Participant also acknowledges that the information provided to the Park Central Development team may be shared with third-party service providers as identified in the assessment of needs and the action plan.
2. FULLY RELEASES, WAIVES DISCHARGES AND COVENANTS NOT TO SUE Park Central Development, its Board, agents, employees, or designees from any and all losses, causes of action, claims, damages, or liability that Participant, Participant’s spouse, child(ren), guests, legally authorized representative, assigns, successors, and representatives may have that relates to, arises out of or is any way connected to Participant’s use of Park Central Development’s Community Resource Counseling services.
3. CONSENTS to the possible release of information to third-party service providers, in order to help meet the goal(s) of the participant as identified within the resource counseling sessions.

By signing below, Participant acknowledges that they have had the opportunity to review, discuss, and ask questions about the terms and conditions contained herein.

PARTICIPANT ACKNOWLEDGES THAT THEY HAVE READ THIS RELEASE OF INFORMATION AND WAIVER OF LIABILITY, UNDERSTAND ITS TERMS, UNDERSTAND THAT THEY WILL BE GIVING UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE OR GUARANTEE BEING MADE.

Required Documentation to Upload:

• Photo ID
• Proof of Income for all adults (18+) in household. Acceptable proofs include: two (2) months worth of paychecks (within the last 3 months), SSI/SSDI 2020 Award Letter, pension letter,
• Proof of Residency: Applicant’s address including the zip code of the housing location. Acceptable forms of proofs include current utility bill,home insurance proof, phone or cell phone bill, bank statements, etc.