[ ] By checking box 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.
[ ] By checking the box, I understand that any documents (forms, pictures, books, and audio/visual) will not be returned. Please send copies only.
[ ] By checking the 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.
(When sending via email, type your name and the word "signed".)
Send "Release" form via Mail or e-mail to:
Joseph Kelly/ Patrick Ryan
1300 S. 13th Street
Philadelphia, PA 19147