Legal FOIP Release Form

LEGAL FOIP RELEASE FORM

Releasor Name:   Releasor Address:

Date of Birth: Month Day Year   Government ID/Reference No.:

Custodian / Public Body Name:   File / Reference No.:

Recipient Name (to whom information will be released):

RECITALS

WHEREAS the Releasor is an individual who is the subject of certain personal information held by the Custodian and seeks to authorize disclosure of that personal information to the Recipient for the limited purpose set out below;

WHEREAS the Custodian requires an express, written authorization from the Releasor in order to disclose personal information pursuant to applicable freedom of information and privacy legislation and the Releasor wishes to provide such authorization on the terms contained in this Release;

WHEREAS the Recipient requires access to such personal information for the specific purposes described below and agrees to use and protect the information in accordance with the terms of this Release;

NOW THEREFORE

In consideration of the mutual covenants contained in this Release and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

1. AUTHORIZATION

The Releasor hereby authorizes the Custodian to disclose the Releasor's personal information to the Recipient. This authorization is limited to the categories of information checked below and to the specific records and date ranges described in Section 2. The Custodian may rely on this Release and is authorized to provide copies of records as required to give effect to this Release.

Categories of information to be disclosed (check all that apply):

 Medical and health records
 Employment and personnel records
 Education and academic records
 Financial records, including billing and payment information
 Other (specify):

2. SPECIFIC RECORDS AND PURPOSE

Specific records, date ranges or identifying details to be disclosed (describe with specificity to permit the Custodian to locate records):

Purpose for which the Recipient may use the information (must be specific and limited):

3. DURATION

Effective Date: Month Day Year

This Release shall remain in effect until: (select one)  revoked in writing by the Releasor

Or until (specify end date): Month Day Year

4. DISCLOSURE TO THIRD PARTIES AND SUBCONTRACTORS

The Recipient may disclose the personal information received under this Release to agents or subcontractors solely to the extent necessary to accomplish the Purpose, provided that the Recipient (i) obtains written agreements from such agents/subcontractors imposing confidentiality and use restrictions at least as protective as those in this Release and (ii) remains responsible for any acts or omissions of those agents or subcontractors with respect to the personal information.

5. REVOCATION

The Releasor may revoke this Release by giving written notice of revocation to the Custodian and the Recipient at the addresses set out in Section 9. Revocation is effective only upon actual receipt by the Custodian. Revocation shall not affect disclosures made by the Custodian or Recipient prior to receipt of the revocation.

6. CONFIDENTIALITY, USE AND SECURITY

The Recipient shall: (a) use the personal information only for the Purpose; (b) safeguard the personal information with administrative, technical and physical controls that meet or exceed customary industry standards; (c) not copy, disclose or use the information for any other purpose without the Releasor's prior written consent; and (d) securely destroy or return the information upon expiry or earlier termination of this Release, except as required by law.

7. INDEMNITY AND LIMITATION OF LIABILITY

The Recipient agrees to indemnify, defend and hold harmless the Custodian and its officers, employees and agents from and against any claims, liabilities, losses, damages, costs and expenses (including reasonable legal fees) arising out of the Recipient's unauthorized use or further disclosure of the personal information. The Custodian shall have no liability for disclosures made in good faith and in accordance with this Release and applicable law.

8. NOTICES

Notices to Releasor:

Notices to Recipient:

Notices shall be deemed given on the date of delivery if delivered in person, on the date of electronic transmission if sent by email during normal business hours, or three business days after mailing if sent by certified mail.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

Governing Law: This Release shall be governed by and construed in accordance with the laws of the province or state of and the applicable federal laws of that jurisdiction.

Entire Agreement: This Release contains the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings, whether oral or written.

Severability: If any provision of this Release is found to be invalid or unenforceable by a court of competent jurisdiction, the remaining provisions shall remain in full force and effect and the invalid or unenforceable provision shall be replaced by a valid provision that most closely reflects the parties' original intent.

10. AMENDMENT; WAIVER; COUNTERPARTS

Amendment: This Release may be amended only by a written instrument signed by the Releasor and the Recipient.

Waiver: No waiver of any breach of this Release shall be effective unless made in writing and signed by the party granting the waiver.

Counterparts: This Release may be executed in counterparts and by electronic or facsimile signature, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

11. ACKNOWLEDGEMENT AND CERTIFICATION

The Releasor acknowledges that the Releasor has read and understands the contents of this Release, that the Releasor's consent is voluntary, and that the Releasor may request a copy of this Release. The Releasor certifies that the information provided in this Release is true and correct to the best of the Releasor's knowledge.

 I certify under penalty of perjury that the foregoing is true and correct and I am the person identified as Releasor or am authorized to sign on behalf of the Releasor.

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