Agreements and Releases (1b)

1) Document Releases

[ ] 
By checking box I give my permission for the copying and distribution of “Background Information For Case Evaluation (1a),” and any other materials provided, to additional thought reform consultants, and/or mental health professionals, and/or ex-members, and/or others for the purposes of evaluation and preparation.

[ ]  By checking box I understand that documents (forms, pictures, books, and audio/visual) will not be returned. Please send copies only.



2) Research Release

[ ] By checking box I give my permission for the copying and distribution of “Background Information For Case Evaluation,” and any other materials provided, for the purposes of follow up and research and development.




3) Fees Agreement

[ ] By checking box I acknowledge that I have received, read, understand and accept Patrick Ryan's "FEE SCHEDULE (1c)," dated 12/16, and effective until 12/31/17,


[ ] By checking box I acknowledge that I have received, read, understand Joseph Kelly's "FEE SCHEDULE (1d)," dated 12/16, and effective until 12/31/17.



4) Refunds and Cancellation Policy

[ ] By checking box I acknowledge that I have received, read, understand and accept "Refunds and Cancellations Policy - Patrick Ryan" (5a)," dated 10/2013.


[ ] By checking box I acknowledge that I have received, read, understand "Refunds and Cancellations Policy - Joseph Kelly" (5b)," dated 10/2013.




Name:______________________
Signed: _____________________  (When sending via e-mail, type your name and the word "signed".)
Date:_______________________


1300 S. 13th Street
Philadelphia, PA 19147
Phone: 215.467.4939; e-mail: pryan19147@gmail.com

©1997-2014 Joseph Kelly and Patrick Ryan
Rev: 01/01, 07/03, 8/04, 9/05,  4/06, 9/06/ 12/08, 10/11, 11/12, 10/13, 7/14, 12/16 “Agreements and Release”