Releases - Joseph Kelly/Patrick Ryan

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Document Release
Permission to copy and distribute documents Check one

1. [ ]  I give my permission for the copying and distribution of “Background Information For Case Evaluation,” 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.

2. [ ]  I do not give my permission for the copying and distribution of “Background Information For Case Evaluation,” 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.

Agreement of non return of document Check to accept

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

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Research Release

 
Research Permission Check one

1. [ ] 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.

2. [ ] I do not 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.

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Fees Agreement


Fees Agreement Check to Agree and accept

1. [ ] I acknowledge that I have:

received, read, understand and accept Patrick Ryan's "FEE SCHEDULE," dated 11/12, and effective until 12/31/13,

2. [ ] I acknowledge that I have:

received, read, understand Joseph Kelly's "FEE SCHEDULE," dated 11/12, and effective until 12/31/13.

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Refunds and Cancellation Policy Acceptance

Fees Agreement Check to Agree and accept

1. [ ] I acknowledge that I have:

received, read, understand and accept Refunds and Cancellations policy - Patrick Ryan," dated 11/12, and effective until 12/31/13,

2. [ ] I acknowledge that I have:

received, read, understand Refunds and Cancellations policy - Joseph Kelly," dated 11/12, and effective until 12/31/13.

Name:______________________

Signed: _____________________           Date:_______________________

(When sending via e-mail, type your name and the word "signed.)

Send via (Mail, Fax, e-mail):

1300 S. 13th Street

Philadelphia, PA 19147

Phone: 215.467.4939; Fax: 267.386.2329; e-mail: pryan19147@gmail.com

©1997-2012 Joseph Kelly & Patrick Ryan
Rev: 01/01, 07/03, 8/04, 9/05,  4/06, 9/06/ 12/08, 10/11, 11/12 “Release”