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Tell Us About Yourself 
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I have requested the assistance of Inclusion Nova Scotia (InclusionNS) and participation in an InclusionNS program. Or I have requested the assistance of Inclusion Nova Scotia and or participation in an InclusionNS program on behalf of my child or a person under my care.

 

I consent to InclusionNS, its employees or other representatives:

 

  • Obtaining and collecting personal information about me;

  • Entering and storing personal information in an electronic database; 

  • Releasing information to or consulting with professionals, service providers, community organizations, or other individuals, as InclusionNS may deem necessary. Examples include social workers, family physicians, educators, mental health workers, home support agencies, and disability organizations, employment agencies; and,  

  • Speaking on my behalf with professionals, service providers, community organizations, or others to help achieve my goals or resolve an issue. 

 

InclusionNS will only collect and release information necessary to provide the assistance and or support that I have requested or for a purpose that is consistent with my request. 

 

This consent applies until I end it, which I can do at any time. I will end this consent in writing. I understand that ending this consent may affect the ability to receive assistance from InclusionNS or to participate in an InclusionNS program. 

Thanks for submitting!

Deborah will contact you soon for more details.