Police Officers should fax completed form to the nearest Women's Center Office at:

Jenkintown: 215-885-8156

Norristown: 610-279-7740

Pottstown: 610-970-0705

Lansdale: 215-853-8065

Bryn Mawr: 610-525-1529

PERMISSION SLIP
I hereby give the Police Department permission to release my name, address and phone number to the Women's Center of Montgomery County. I am aware that I may contact the Women's Center at the following 24-hour hotline numbers:
Toll Free Hotline: 800-773-2424
Jenkintown Office: 215-885-5020
Norristown Office: 610-279-1548
Pottstown Office: 610-970-7363
Lansdale Office: 215-853-8060
Bryn Mawr Office: 610-525-1427
Name
Address
Home Telephone Number:		Best Time to Call:
Work Telephone Number:		Best Time to Call:
__________________________________________________
Signature                                                  Date
Responding Officer(s) Name(s) & Badge Numbers
Police Report Number:		Arrest Made?	Yes No