COM: Appendix 3 – Rationale and Permission to Use Name and Address

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FLORIDA DISCIPLES REGIONAL CHURCH: Confidential Document

From time to time, the COM will need to send to you, or request from you, important information. Our purpose would be to contact you for reasons that have a direct bearing on your preparation for ministry. Due to privacy laws and confidentiality requirements of seminaries and Region, the COM must ask your permission to contact you at your residence and to share this information with appropriate church-related parties. Please read and sign to agree or to decline to provide the following information:

Date: *

Name [First, Middle (Use n/a if no middle name) and Last] *

Address (Street, City, State and Zip Code) *

Phone *

Email *

(If appropriate) Seminary Contact Mail Address:

(If appropriate) Seminary Phone

Please select one option below: *

I give my permission to be contacted. I understand that this information may be shared with regional congregations and organizations.
I decline to give this information

I understand that this information will be valid from the current school year until I have completed my relationship with the COM; and if there are changes, I will contact the Regional Office to update information.

By entering my name in this box I am signing this form and attest it to be true and accurate to the best of my knowledge *

Name