Fields with a * are required. Please fill in this information or form will not submit. Name of Parent/Guardian * Email A confirmation will be send to this address Date of birth * Address * City and State * Zip * Phone Number Total number of children in household * Total number of children in grades K-12 * Do you have health coverage * Yes No Do you want information about Pre-K Programs for children under age 5 * Yes No Have you been financially impacted by the COVID-19 pandemic? * Yes No Children’s Information Please fill out the information for each child below Child 1 Please fill out the below information in full. 1. Child's Name - 2. Relationship - 3. Date of Birth - 4. Gender - 5. Grade (next year) - 6. School Name - Child 2 Please fill out the below information in full. 1. Child's Name - 2. Relationship - 3. Date of Birth - 4. Gender - 5. Grade (next year) - 6. School Name - Child 3 Please fill out the below information in full. 1. Child’s Name - 2. Relationship - 3. Date of Birth - 4. Gender - 5. Grade (next year)- 6. School Name - Child 4 Please fill out the below information in full. 1. Child’s Name - 2. Relationship - 3. Date of Birth - 4. Gender - 5. Grade (next year) - 6. School Name - Child 5 Please fill out the below information in full. 1. Child’s Name - 2. Relationship - 3. Date of Birth - 4. Gender - 5. Grade (next year) - 6. School Name - The Jackson County United Way Assistance Network is a shared computerized record keeping system that captures information about people experiencing need for emergency services, including but not limited to assistance with utility bills, medications, rent/mortgage payments, etc. Jackson County United Way (JCUW) collects data on behalf of participating agencies of the Charity Tracker. I understand that all the information gathered about me is personal and private and that I do not have to participate in the Jackson County United Way Assistance Network. I have had an opportunity to ask questions and to review the basic identifying information, which is authorized by this release. I also understand information about non-confidential services provided to me. This release of information will remain in effect for three (3) years from the date noted under my signature at the bottom of this page unless I make a formal request to this organization that I no longer wish to participate. Confidentiality & Privacy: It is the policy of the Jackson County United Way (JCUW) that the internal business affairs of the organization and all program participants’ information represent JCUW assets that each Board member, staff, volunteer, and representative has an obligation to protect. Information designated as confidential, privileged or nonpublic may not be disclosed to anyone outside the organization and may be disclosed within the organization only on a “need to know” basis. In addition, Board members, staff, volunteers and representatives have a responsibility to avoid inappropriate disclosure of JUCW matters, its employees, its programs and its program participants. Board members, staff, volunteers and representatives authorized to confidential, privileged or nonpublic information must treat the information with proprietary JCUW property for which they are personally responsible. The privacy rights of all individuals in performance of their JCUW duties will be respected. I authorize JCUW to share my basic, identifying and non-confidential service transaction or information with other agencies. I authorize the use of a copy of this original to serve as an original for the purpose stated above. I further authorize the JCUW to share my dependent’s basic, identifying and non-confidential service transaction or information. RELEASE OF INFORMATION: JCUW has an ethical and legal obligation to respect the privacy of our clients (Such as the Volunteer Income Tax Assistance clients) and to protect and maintain the confidentially of all information we obtain about clients, their friends, acquaintances and family members in the course of providing services to them. Client records are legally protected confidential records and are treated as such. This means that client records maintained by JCUW are kept in a locked file at all-time except when being reviewed or updated and shredded upon completion of services. Client Confidentiality will be broken only under certain conditions. 1) When the client is a threat to others or self. Under IN law, any individual who has a reason to believe a child is a victim of abuse or neglect has the duty to make a report; therefore, each citizen of Indiana is considered a “mandated reporter.” While reporting child abuse is everyone’s responsibility, Indiana law requires some certain occupations to do so. These professional reporters are staff members in a medical or other private or public institution, school facility or agency. These reporters are legally obligated by their profession to report alleged child abuse or neglect. 2) If client files are subpoenaed. CONSENT TO DISCLOSE: JCUW must report program results to our grant funders and donors. Unless authorized by law, we cannot disclose, without your consent, your personal information to third parties for purposes other than direct service referrals. PHOTO RELEASE: I agree to permit photographs, video or digital tapes, movies and/or sound recordings of myself (or my child/ren or significant other) for the purpose of television, radio, newspaper or outdoor advertising, billboards, videos, printed materials, internet and/or news stories. I understand that I (or my child/ren or significant other) will not receive payments for these pictures and will have no right to view or approve them before or after they have been used. I hereby waive all claims for any compensation for such use, now or anytime in the future. I understand there is no time limit to this agreement. AGREEMENT: I understand the purpose of this policy and acknowledge that I have read this document and JCUW will hold my personal information confidential and will share general program statistics with our granters, donors, and media relations. No personal information will be shared without my consent. 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