HSDE Client Intake Form

Intake Request Form

Purpose of Collection and Use

I consent to your organization collecting, recording, storing, and using my personal information for the purpose of providing services and communications related to events, workshops, programs, and other relevant activities. This may include administrative purposes, service coordination, follow-up communications, and internal record-keeping.

Types of Information

I understand that the personal information collected may include my name, contact details, and any other information I voluntarily provide that is necessary to deliver services or communications effectively.

Storage and Security of Information

I understand that my personal information will be stored securely and that appropriate administrative, technical, and physical safeguards will be in place to protect my data from unauthorized access, loss, misuse, or disclosure.

Sharing of Information

I consent to the sharing of my personal information with trusted third-party partners of your organization solely for the purpose of delivering services and communications as described above. I understand that such third parties are required to protect my information and use it only for authorized purposes.

Retention of Information

I understand that my personal information will be retained only for as long as necessary to fulfill the purposes for which it was collected, or as required by applicable laws or organizational policies.

Withdrawal of Consent

I am aware that I have the right to withdraw my consent at any time by contacting your organization. I understand that withdrawing consent may limit or affect the services or communications that can be provided to me.

Acknowledgement and Consent

By providing my information and/or participating in your organization’s services, events, or communications, I acknowledge that I have read, understood, and agree to the terms of this consent.