Non-Consent Form

This form must be notarized.

Print Complainant’s Name:

(first) (middle initial) (last)
Male Female
Complainant’s Gender:

Complainant’s Date of Birth:

Complainant’s Address:

Complainant’s Telephone:

I, the above-listed complainant, hereby did not give consent to anyone to share or/and use my personal identifying
information or documents belonging, assigned, or otherwise associated with me with other service providers in
connection with my care, including accessing and sharing my job, residential, bank accounts, social media accounts,
phone numbers, medical under HIPPA laws, and if applicable, health and police records.

My name, photograph or image and job information will not be released by anyone to any anyone including my
parents or family members, office or training facilities, financial aid programs, agencies, etc. other than myself.

I never permit anyone to hold information gathered about me from the various agencies/neighbours/colleagues or
other sources and any act, document, speech, messages, rumours and any efforts that may reveal me and my family
identity without my permission, are strictly prohibited that may affect my rights under the Data Protection Act.

I never allow anyone on my behalf;

 to obtain credit, money, goods, services, employment, or any other thing of value or benefit;
 to avoid civil or criminal process or penalty;
 to harm my or any person under my legal guardianship’s reputation, property, person, or estate.

(Complainant’s signature)

Notary Information Below:

day of ,
This

My commission expires

Notary Information Below:

day of ,
This

My commission expires