Youth Fund Application 

    Release of Information Consent
    By submitting this application, I understand that my information may include protected health information. I authorize the release of my information to any person or agency necessary to meet my service needs, including, but not limited to, vendors and partner agencies. This information will be used solely for the purpose of assessing, arranging, and meeting my individual service needs. I release Tri-County Health Network and its partners from any liability related to the sharing of this information.

    Translate »