I hereby give my permission for the release of information relevant to providing services and meeting my needs to the staff of the Sexual Assault/Spouse Abuse Resource Center, Inc. This release will be effective for the duration of my program participation.
Name/Agency: Governor’s Office of Crime Prevention, Youth, and Victim Services
Relationship to Client: Certifying body of SARC AIP, to audit/monitor/evaluate records
Address: 100 Community Place
Crownsville, MD 21032