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SHARING CENTER OF CENTRAL BREVARD ONLINE APPLICATION FOR CLIENT SERVICES
SHARING CENTER OF CENTRAL BREVARD ONLINE APPLICATION FOR CLIENT SERVICES
Last 4 of SSN
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0 / 4
Today's Date
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First Name
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Last Name
Date of Birth
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Month
*
Day
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Year
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Select Gender
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Select Gender
Male
Female
Transgender
Marital Status
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Select Gender
Single
Married
Divorced
Widowed
Phone
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Street Address
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Apartment, suite, etc
City
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State/Province
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ZIP / Postal Code
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Length of Stay at Current Address
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Veteran
Yes
No
U.S. Citizen
Yes
No
Health Insurance
Yes
No
Living Situation
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Rent Home
Own Home
Transitional Housing
Stays with Friend/Family Member
Homeless
Requesting Assistance For
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Food
Clothes
Household Items
Other
TOTAL HOUSEHOLD MONTHLY INCOME:
INCLUDES BENEFITS FOR CHILDREN
Employment
Children's Disability
Unemployment
Death Benefits
SSI
Retirement
SSDI
Pension
VA Disability
Child Support
Workman's Comp
Self-Employed
TANF
Food Stamps
Race/Ethnic Group
White
African American
Native American or Alaskan Native
Asian
Hispanic
Other
Number in Household
*
Adults
*
Children
Today's Date
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HOUSEHOLD MEMBER #1
Name
Date of Birth
Month
Day
Year
Select Gender
Select Gender
Male
Female
Transgender
Last 4 of SSN
*
0 / 4
Relationship
HOUSEHOLD MEMBER #2
Name
Date of Birth
Select Gender
Select Gender
Male
Female
Transgender
Last 4 of SSN
*
0 / 4
Relationship
HOUSEHOLD MEMBER #3
Name
Date of Birth
Select Gender
Select Gender
Male
Female
Transgender
Last 4 of SSN
*
0 / 4
Relationship
HOUSEHOLD MEMBER #4
Name
Date of Birth
Select Gender
Select Gender
Male
Female
Transgender
Last 4 of SSN
*
0 / 4
Relationship
HOUSEHOLD MEMBER #5
Name
Date of Birth
Select Gender
Select Gender
Male
Female
Transgender
Last 4 of SSN
*
0 / 4
Relationship
HOUSEHOLD MEMBER #6
Name
Select Gender
Select Gender
Male
Female
Transgender
Date of Birth
Last 4 of SSN
*
0 / 4
Relationship
HUD/HMIS Client Release
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Yes I Understand
I understand and acknowledge that this agency is a member of the HUD/Homeless Management Information System, hereafter known as “HUD/HMIS”, and I consent to and authorize the collection of data and information maintained by this agency to “HUD/HMIS” and affiliated agencies, provided such agency is a party to the “HUD/HMIS” agency agreement under which the agency has specifically agreed to share information. These agencies include, but are not necessarily limited to participants in the “HUD/HMIS” grant, and the United Way Outcome Measures Pilot Project. The data, information and records gathered and prepared by the agency and “HUD/HMIS” will be included in the database and may be utilized by “HUD/HMIS” and affiliated agencies to: a) provide individual case management; b) produce reports regarding utilization of services; c) track individual program outcomes; d) provide accountability for individuals and entities that provide funds for use in providing services in Brevard County; e) identify unfilled service needs and plan for the provision of new services; f) allocate resources among agencies engaged in the provision of services in Brevard County and g) be used for all other uses to be deemed appropriate by “HUD/HMIS”. I understand and acknowledge that my data and information may be used in aggregate data along with information of other individuals served by the Agency for the purposes described above. I understand and acknowledge that data, information and records pertaining to the services provided to me by the Agency will only be disclosed to agencies, individuals and entities other than “HUD/HMIS” only with my written authorization. I understand and acknowledge that the data pertaining to the services provided to me may include medical/health information and other information the privacy of which may be protected by federal or Florida State laws and expressly consent to the release of such information in accordance with these protections. I understand and acknowledge that I have the right to a) inspect, copy and request amendment of all records maintained by the Agency related to the provision of services and to receive a paper copy of this form; and b) to file a grievance if I believe my privacy rights have been violated. This grievance must be submitted in writing to the agency’s Complaints Manager and will be responded to in accordance with the Agency’s Privacy Policies and Procedures. I understand and acknowledge that I have the right to opt out of having my data, information and records disclosed to “HUD/HMIS” and affiliated agencies by providing notice to the Agency and that I am entitled to services regardless of my decision. I further understand and acknowledge that I may revoke this consent at any time by providing written notice to the agency. THE SHARING CENTER OF CENTRAL BREVARD DOES NOT DISCRIMINATE IN IT’S SERVICE OF CLIENTS. SERVICES ARE PROVIDED REGARDLESS OF RACE, COLOR, NATIONAL ORIGIN, GENDER, RELIGION, AGE, DISABILITY, POLITICAL BELIEFS, SEXUAL ORIENTATION, AND MARITAL OR FAMILY STATUS.
ELECTRONIC SIGNATURE
Electronic Signature
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