HOME SECURITY SAFETY UPGRADES

Consent Form
First/Given Names: Surname:
DOB: Client No:
Address of Property Requiring Security Safety Upgrade:

SERVICE USER STATEMENT

I understand that the Gladstone Women’s Health Centre will share information that relates directly to
the intended Home Security Safety Upgrade. I understand that information will be shared with the
property owner, as this will allow the Gladstone Women’s Health Centre to gain permission to
complete the Home Security Safety Upgrade. I understand that the Gladstone Women’s Health Centre
will maintain confidentiality and only share information that is necessary for the safety modifications
to occur.
I understand that sharing information for the purpose of conducting a Home Security Safety Upgrade
may involve contacting:
 Department of Housing and Public Works
 Property Owner/s
 Real Estate Agencies
 Regional Housing Limited Safety Upgrades Officer
 Contractor and/or Tradesman Completing the Modifications

I understand that if I agree to my information being shared, I have the right to limit how much is
shared or withdraw my agreement at any time.
Please note: The Gladstone Women’s Health Centre or Regional Housing Limited are not responsible
for the maintenance of any items that are installed under the Home Security Safety Upgrades.

DECLARATION:
I consent/do not consent to my information being shared for the purposes of a Home Security Safety
Upgrade.
Print name: ____________________________________________________
Sign: ____________________________________________Date: __________________

Ref: /conversion/tmp/activity_task_scratch/762074387.docx