Authorization for Disclosure of Information to Act Five

Redeemer University is excited that Act Five is on the road to becoming its own independent organization beginning May 1, 2023.

As part of this transition phase, Act Five would like to continue to communicate with key supporters after May 1st.

By completing the form below, you are authorizing Redeemer University to disclose the following personal information to Act Five Initiatives CRN # 71562 7105 RR0001 for the purposes of data collection and communication.

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Personal Phone (home or cell)(Required)

Additional personal phone

Business phone

Personal email(Required)

Business email

I understand the terms of the consent to share personal information as stated above.(Required)

Yes

Redeemer University agrees to abide by the consents noted above and will release this information upon submission. No other details outside of what is noted will be released as per University security and privacy policies.

NOTICE TO DONORS: Any and all donations to Act Five Initiatives after May 1, 2023 must be directed to or established with the new organization. To do this please contact: info@actfive.ca

I hereby give Redeemer University permission to share my contact information as noted above to Act Five Initiatives so that the new charitable organization may keep me informed and provide future communications to me. I understand that all of the fields completed are optional and customizable according to my wishes.(Required)

Yes