If you object to receiving services from us based on the religious character of our organization, please complete this form and return it to the program contact identified above. If you object, we will make reasonable efforts to refer you to another service provider. We cannot guarantee, however, that in every instance, an alternative provider will be available. With your consent, we will follow up with you or the organization to which you were referred to determine whether you contacted that organization.

Please check if applicable:

(  )  I want to be referred to another service provider.

If you checked above that you wish to be referred to another service provider, please check one of the following:

(  )  Please follow up with me or the service provider to which I was referred.

Name:

Best way to reach me (phone/address/email):

(  )  Please do not follow up.

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