RELEASE: I understand and agree that the information contained on this form may be released for statistical purposes, and I agree to the release of information for that limited purposed only. I understand that any release of information in identifiable form may be accompanied by a signed consent form and that the information will not be used as an eligibility determination or effect participation as a recipient unless a law has specifically restricted program participation.

Behring Senior Center does not discriminate based on age, race, gender, national origin, color, creed, religion, political affiliation, or physical or mental disabilities in its employment practices or the provision of services except where it is a requirement of law.