Assistance Application

Client Consent and Release of Information

I give permission to Hillcrest Platte County to collect my personal and household information. I understand that authorized agencies may use the information I share in my community for the purpose of;

1. Assessing the needs of low income, homeless or other people with special needs in order to get better assistance, and to improve their current or future situations
2. Improving the quality of care and service for people in need.
3. Tracking the effectiveness of community efforts to meet the needs of people who have received assistance.
4. Reporting data on an aggregate level that does not identify specific people or their personal information.
I understand that:
All agencies will treat my information in a professional and confidential manner. Signing this release form does not guarantee that I will receive assistance.
My information may be shared with a third-party, (utility provider, landlord, etc.) to process the services I have requested.
I have the right to a printed copy of my information on file.

Check this box to give consent for your photo to be uploaded with your information(Required)

Permission granted.

Client Name(Required)

First Last

Date

Agency representative name: David Johnson

Date

After signing this form, you decide you no longer would like your information utilized through Hillcrest Platte County, please complete the client revocation form. If you do not revoke this authorization, it will automatically expire one year from the date you sign and date this form.

Assistance Application for the Blessings Program

For Blessings Use Only: Pay Forward Program: ◻️ Payback Program: ◻️ Notes:

Name(s) of Applicant(s)(Required)

First Middle Last

Physical Address:(Required)

Street Address Address Line 2 City State ZIP Code

Marital Status

Single

Married

Divorced

Separated

How Many people live in your home?

How many minors?

Names and birthdates for all:

Name/birthdate

Employment Information For Each Resident Including Address And Telephone Number of Employer(s):

Tell Us About Your Circumstances And Needs Including The Name And Address Of Landlord Or Mortgage Company:

Have You Sought Assistance Elsewhere?

Yes

What Assistance Was Granted?

Please Tell Us Any Additional Information You Would Like Us To Know:

Attach A Copy Of The Missouri Driver’s License(s) For Each Adult With This Application.

Max. file size: 12 MB.

Attach A Copy Of The Missouri Driver’s License(s) For Each Adult With This Application.

Max. file size: 12 MB.

By signing below, I agree that the information presented above is accurate and truthful to the best of my knowledge. Further, I give permission to the staff of the Hillcrest Platte County to verify the above information and/or contact other service agencies on my behalf. I also understand that my information may be shared with other social service agencies.

Signature(s)

First Last

Signature(s)

First Last