Voluntary Information Clause Samples

Voluntary Information. The following information may be used to select roommates based on language skills, where applicable, and for statistical purposes. First Nations ( ) Band: Band Number: Tribal Agency: Non-Status Aboriginal person ( ) Métis ( ) Other (please specify) ( )

Voluntary Information. You may choose whether or not to provide voluntary information, and failure to provide this information will not have a negative impact on your application form. The information that is voluntary assists us in matching roommates, providing more detailed programming better suited to your needs and allows us to compile statistics as required by our funders. A United Way Member Agency These rules are an attachment to the Rental Agreement between the ▇▇▇▇▇▇▇▇▇ ▇▇▇ Society of Manitoba, Inc. and (tenant’s name) and form part of that binding agreement. In signing the Rental Agreement and this document, the tenant agrees to abide by these House Rules and is aware that breach of any of these House Rules or the Rental Agreement is grounds for termination of the tenancy. 1) The tenant will keep the premises in a reasonable state of cleanliness and good repair and will inform The ▇▇▇▇▇▇▇▇▇ ▇▇▇ Society immediately upon discovering any damage or disrepair in the suite. 2) The tenant will not deliberately or negligently destroy, damage or remove any fixtures on the premises, nor any other property of The ▇▇▇▇▇▇▇▇▇ ▇▇▇ Society that was provided to the tenant during her tenancy. 3) The tenant will treat other tenants, as well as representatives of The ▇▇▇▇▇▇▇▇▇ ▇▇▇ Society, with respect and courtesy. Representatives of The ▇▇▇▇▇▇▇▇▇ ▇▇▇ Society similarly agree to treat tenants in a respectful and courteous manner. 4) The tenant will not use violence on the premises, nor will she bring any weapons on the premises or permit anyone else to bring weapons on the premises. 5) The tenant will not smoke on the premises, nor will she permit anyone else to smoke on the premises. 6) As the Premises are shared housing, the tenant will not permit any non-tenant's on the premises (other than authorized maintenance personnel or others authorized by The ▇▇▇▇▇▇▇▇▇ ▇▇▇ Society). 7) The tenant will not permit any alcohol or drugs on the premises. 8) The tenant will not permit any pets on the premises. 9) The tenant will not leave the front door unlocked at any time. 10) The tenant will not go on the roof of the building next door (i.e., through a window), nor will she permit any person except authorized maintenance personnel or representatives of ▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇  ▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇  ▇▇▇ ▇▇▇  Phone: (▇▇▇) ▇▇▇-▇▇▇▇  Fax: (▇▇▇) ▇▇▇-▇▇▇▇ email: ▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ ● ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ the ▇▇▇▇▇▇▇▇▇ ▇▇▇ Society to go on the roof of the building. The tenant will not take the scr...

Voluntary Information. Clients and family members often express preferences for service provider of a particular ethnic background or gender. Your completion of the information below will allow DCF to be more responsive when such a preference is requested. If you volunteer to provide the following information, it will only be used when a client or family member indicates such information is important in selecting service provider. The information collected will not be released to any other party, except in aggregate form. Ethnic background: ❑ African American/Black ❑ Asian/Pacific Islander ❑ Caucasian/White ❑ Native American/Eskimo ❑ Puerto Rican ❑ Other (not listed above) Gender: ❑ Female ❑ Male Please indicate which DCF Area Offices you would like to receive referrals from (check all that apply). Bridgeport Danbury Hartford Manchester/Rockville Meriden Middletown Milford New Britain New Haven Norwalk Norwich Torrington Waterbury Willimantic Address: City: State: I have provided babysitting or childcare: Years of Experience Occasional Babysitting Routine Scheduled Childcare □ Child age 0-2 □ □ □ Child age 3-5 □ □ □ Child age 6-12 □ □ □ Child age 13-16 □ □ □ Child age 17 and above □ □ □ Child who needs special health care or treatment:(Please specify) □ □ □ Other (Please specify): □ □ I have acted as a volunteer in the community with children and youth including: Child age 1-5 Child age 6-12 Child age 13 and above □ Youth Group □ □ □ □ Church Group □ □ □ □ Big Brothers or Big Sisters Program □ □ □ □ Youth Sports □ □ □ □ School Aide □ □ □ □ Red Cross or Other Public Health Institution □ □ □ □ YMCA Activities □ □ □ □ Reading or Storytelling □ □ □ □ Other (Please specify): □ □ □ I certify under penalty of perjury that all the information provided is true and correct to the best of my knowledge. APPLICANT SIGNATURE: _ DATE: ® DCF has contracted with Advanced Behavioral Health, Inc. (ABH ) as the credentialing vendor for the DCF Credentialing Program. ABH will assist DCF in facilitating the provider application process. For purposes of making this application to become a participating DCF provider, the Applicant certifies that all information provided to DCF or ABH is true and correct to the best of the Applicant’s knowledge and belief. The Applicant agrees to notify DCF or ABH promptly if there are any material changes in the information provided, whether prior to or after acceptance as a DCF provider. The Applicant understands and agrees that if DCF or ABH determines that this appl...