Consent to Share Personal Information

Please read the following statement and give consent by typing your name below:

I agree that any personal information that I choose to release to Conversation Café will be held in confidence and in a secure location. Access to this information will be limited and only accessed by Café leaders. This information may include things such as my name, phone number, email address, and/or any other information I choose to share. This information will be used solely for the purpose of allowing me to fully participate in and thrive during Conversation Café and will allow Café leaders to contact me upon class cancellation or other changes to schedule.