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Girl with Braids

Confidentiality Waiver & Acknowldgement

Please read and sign the form below.

Receipt of Information Form

I, the undersigned, understand that approved safe contact visitors, volunteers, or House of Hope Board Members may visit the House of Hope residential site. These visitors will complete a confidentiality waiver and acknowledge that all information at the House of Hope programs is confidential. These visitors will not disclose any confidential information pertaining to the House of Hope programs. This will include, but is not limited to, all of the discussions related to participants, location of facilities, and all other information obtained while on site at this program.

Receipt of Information Form


, custodian of

have been provided information about the House of Hope for Girls Program services, environment, age ranges and behavioral characteristics of other participants in the program. I have considered this information provided and have determined that the environment is appropriate and does not represent an undue risk to the health and safety of


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