I, do hereby consent to the Bilal Community and Family Centre Newcomer Community Mobilization Initiative releasing and/or disclosing personal information related to myself to the participating agencies as listed below.

PARTICIPATION AGENCIES

Participating agencies include Winnipeg School Division, Winnipeg Regional Health Authority, Manitoba Justice, Winnipeg Police Service, City of Winnipeg, General Child, and Family Services Authority (GA), Manitoba Housing, Employment, and Income Assistance (EIA), Child and Youth Services, Department of Families, Aurora Family Therapy, Victim Service, Probation Service, and newcomer community-based umbrella organizations such as Ethno-Cultural Council of Manitoba (ECCM), MANSO etc.

I am consenting to the disclosure of this information to the participating agencies to allow for collaborative planning for myself pursuant to the Bilal Community and Family Center Newcomer Community Mobilization Initiative for the purpose of:

• Early identification of risk factors and/or barriers to safety, stability, and success
• Coordination of multi-agency case planning for children, youth, and families
• Mobilization of public and/or private, community and family support
• Navigational support
• Proactive planning to reduce crisis and crisis intervention and support.

I am also agreeing to the following:

• To enter the program with the intention of working toward safety, stability, and success.
• To be respectful of Program Saff if I am unable to keep my appointments or, if there are barriers that impact my ability to follow the plan(s) created with my support team.

I understand the following:

• I understand that the risk of self-harm or harm to another will be reported.
• I know that I can withdraw my consent at any time by calling the staff of the Bilal Community and Family Centre.
• Information about the BCFC project, the process, and the role of the hub has been provided to me.
• I authorize the sharing of personal (including where necessary personal health) and individual/family information amongst Hub members as outlined above.

This consent is valid for 356 days from the date I sign this document and, I understand that I can withdraw this Consent in writing at any time and I may do so by contacting the Bilal Community and Family Center Newcomer Community Mobilization Initiative program coordinator at 204-880-2483.