Confidentiality Waiver Form

I, the undersigned (required)

Full name in Hebrew must be provided

ID Number (required)

Date of Signature (required)

I hereby authorize the Department of Social Services in Efrat to request, receive and provide relevant information concerning me and my family. In witness whereof I have signed, I hereby authorize the Department of Social Services in Efrat to request, receive and provide relevant information concerning me and my family. Signed as authorization (required)

I agree

Signature (required)

אני אדם עם מוגבלות ואיני יכול/ה להשתמש בעכבר או באצבע כדי לחתום

Confidentiality Waiver Form

יש לנו נתונים שמורים עבור טופס זה

האם דף זה עזר לך?

Confidentiality Waiver Form

יש לנו נתונים שמורים עבור טופס זה

האם דף זה עזר לך?

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