Giving Respect Inc authority to share information on your behalf

My preferred name and/or contact details are:
I give Respect Inc permission to inform the following people about an incident
Other people I would like you to inform on my behalf....
You can disclose my preferred name:
- Yes
- No
- I don't know
You can disclose my workplace (how you describe it):
You can disclose my location at the time of the incident (how you describe it):
I realise I must be contacted to verify this authority. Please contact me on:
I'm a peer educator, MC member or Respect Inc volunteer, this person gave consent. A little bit about that here, plus your contact details (if you are not the person the incident happened to):

Thank you. Respect Inc take your information seriously.