SHARING CENTER OF CENTRAL BREVARD ONLINE APPLICATION FOR CLIENT SERVICESLast 4 of SSN *0 / 4Today's Date *First Name *Last NameDate of Birth *Month *Day *Year *Select Gender *Select GenderMaleFemaleTransgenderMarital Status *Select GenderSingleMarriedDivorcedWidowedPhone *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Length of Stay at Current Address *VeteranYesNoU.S. CitizenYesNoHealth InsuranceYesNoLiving Situation *Rent HomeOwn HomeTransitional HousingStays with Friend/Family MemberHomelessRequesting Assistance For *FoodClothesHousehold ItemsOtherTOTAL HOUSEHOLD MONTHLY INCOME:INCLUDES BENEFITS FOR CHILDRENEmploymentChildren's DisabilityUnemploymentDeath BenefitsSSIRetirementSSDIPensionVA DisabilityChild SupportWorkman's CompSelf-EmployedTANFFood StampsRace/Ethnic GroupWhiteAfrican AmericanNative American or Alaskan NativeAsianHispanicOtherNumber in Household *Adults *ChildrenToday's Date *HOUSEHOLD MEMBER #1NameDate of BirthMonthDayYearSelect GenderSelect GenderMaleFemaleTransgenderLast 4 of SSN *0 / 4RelationshipHOUSEHOLD MEMBER #2NameDate of BirthSelect GenderSelect GenderMaleFemaleTransgenderLast 4 of SSN *0 / 4RelationshipHOUSEHOLD MEMBER #3NameDate of BirthSelect GenderSelect GenderMaleFemaleTransgenderLast 4 of SSN *0 / 4RelationshipHOUSEHOLD MEMBER #4NameDate of BirthSelect GenderSelect GenderMaleFemaleTransgenderLast 4 of SSN *0 / 4RelationshipHOUSEHOLD MEMBER #5NameDate of BirthSelect GenderSelect GenderMaleFemaleTransgenderLast 4 of SSN *0 / 4RelationshipHOUSEHOLD MEMBER #6NameSelect GenderSelect GenderMaleFemaleTransgenderDate of BirthLast 4 of SSN *0 / 4RelationshipHUD/HMIS Client Release *Yes I UnderstandI 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 SIGNATUREElectronic Signature *Send MessagePlease do not fill in this field.
