Blessings Program

Hillcrest Platte County Blessings Program

To apply for the Blessings Program, please complete the forms and click the Submit button after each form.

Once we have received the three forms, we will begin processing your application.

Complete the form below, hit Submit, and you will be directed to the next form.

Thank you!

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)
Client Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
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)
Physical Address:(Required)
Marital Status
Names and birthdates for all:
Name/birthdate
Name/birthdate
Name/birthdate
Name/birthdate
 
Have You Sought Assistance Elsewhere?
Max. file size: 12 MB.
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)
Signature(s)