Confidentiality Statement


This is to certify that I, a volunteer, mentor, or participant of the Women’s Empowerment Series under Goebel Family Foundation, understand the information (written, verbal, or other form) obtained in the duration of the Women’s Empowerment Series must remain confidential. This includes all information about other volunteers, mentors, and participants, as well as any other information otherwise marked or known to be confidential.

All violations of confidentiality restrictions are considered serious offenses. Penalties under Wisconsin Statutes 51.30(9) include $100 per violation plus actual damages and attorneys’ fees. Fines for willful knowing violations are not less than $500 or more that $1,000 per violation plus actual damages and attorneys’ fees. Penalties for requesting or obtaining information under false pretenses, include fines of not more than $500, 6 months in jail, or both.

Your signature below acknowledges your understanding of the seriousness of maintaining confidentiality and the consequences of breaching confidentiality


I understand that any unauthorized release or carelessness in the handling of this confidential information is considered a breach of the duty to maintain confidentiality.

I further understand that any breach of the duty to maintain confidentiality could be grounds for discipline to include dismissal and/or possible liability in any legal action.

Authorization

  • Date Format: MM slash DD slash YYYY