Cooperative Christian
Ministry
Crisis Center
246 Country Club Drive, PO
Box 1717
Concord, NC 28026-1717
704-786-4709
Address___________________________________________________________
City______________________ Zip Code___________ County______________
Social
Security Number _________ - _____ -
_________
(1.) When you apply at CCM for
assistance we record the names, birth dates, social security numbers, and addresses
of everyone in your household. It is
your responsibility to provide this information and any other documentation we
deem necessary to make a decision about you request.
(2.) This information may be
shared with other organizations and service providers in our community. Organizations that we coordinate services
and resources with include, but are not limited to, Cabarrus and Rowan Depts.
of Social Services, the Salvation Army, Community Free Clinic, and area churches.
(3.) In order to help you we may
also need to contact your landlord, mortgage holder, utility company, oil
company, employer, pharmacy, or any other resource providers for any reasonable
purpose to help make a decision about your application and resolve your crisis.
(4.) If you contact a church or other
organization for help, either now or in the months to come, that church may
call CCM to verify your situation. By
signing below you give us permission to share information in your file with
that church or organization.
You have the right not to permit us
to share any information with the organizations, businesses, and resources
listed above, however, if you choose not to sign this Consent and Release
Form CCM cannot help you.
Your signature below indicates:
(1.)
That you authorize CCM to provide information to the above stated
agencies and resources for the purpose verifying information, determining the
amounts required, committing funds, and paying bills in order to act on your
application and in response to other organizations which you have approached
for help.
(2.)
That the information you provide to CCM is true and correct, and that
if the information you give is found to be false you may be denied assistance.
Your
signature below indicates:
(1.)
That you do not agree to the
above consent. and
(2.) You do not wish to receive the services of CCM.
Client
Signature
__________________________
Date ____________
Witness ________________________________ Date
____________
April 2003