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Family and Income Stability - Consent for Electronic Communication (email/text)

I/We (Name of Applicant/Recipient or person on behalf of applicant/recipient)

Name of Spouse/Partner

Name of Dependent Adult

I acknowledge that all means of communication bear risk to my privacy and may reveal my personal information to other persons. In addition to other means of contacting me, to which I have already agreed, I expressly consent to being contacted by the following electronic means; and I acknowledge that The Corporation of the City of Brantford is not responsible for any unauthorized access to my computer, telephone or accounts (including any data stored in the cloud):

Email to the following email address

Text to the following phone number (999-999-9999)

Agree to Terms

I acknowledge that I have read and understand this consent.

I have been provided an opportunity to ask questions related to this Consent and my questions were answered.

I understand that I can withdraw my/our consent at any time and this request can be submitted via email but the only communication you will receive in response is confirmation of your withdrawal of consent.

Signed in (City/Town) Ontario,

and dated this (mm/dd/yyyy)

Signature (Applicant/Recipient)

Signature (Spouse/Partner)

Signature (Dependent Adult)

Signature (Witness)

Notice of Collection (Freedom of Information and Protection of Privacy Act/ (Municipal Freedom of Information and Protection of Privacy Act): This information is collected under the legal authority of the Ontario Disability Support Program Act, 1997, sections 5,10, 45 & 46 or the Ontario Works Act, 1997, sections 7, 8, 15,57 & 58, Child Care & Early Years Act, 2014, Section 71, Subsections 1-5, Housing Services Act, 2011,Chapter 6, Schedule 1, for the purposes of determining and verifying initial and/or ongoing eligibility for assistance; and may be used for (i) the administration of social assistance programs; (ii) contacting you; (iii) City’s insurance purposes; (iv) collation of group and metadata; (v) assessment of the programs; and (vi) as otherwise permitted or required by law. Questions regarding the collection, use or disclosure of this personal information may be directed to the City’s Director, Social Assistance & Homelessness, 220 Colborne Street, Brantford, ON N3T 5R7, (519) 759-3330.