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Christmas Assistance Referral 2022

  1. Best contact number to reach you.
  2. Email address
  3. Are you willing to allow direct contact from donor?*
  4. Please answer the following for household members:
  5. Age of household member.

  6. Male or Female*
  7. Interests, hobbies, wish list, etc.

  8. Age of household member.

  9. Male or Female
  10. Interests, hobbies, wish list, etc.

  11. Age of household member.

  12. Male or Female
  13. Interests, hobbies, wish list, etc.

  14. Age of household member.

  15. Male or Female
  16. Interests, hobbies, wish list, etc.

  17. Age of household member.

  18. Male or Female
  19. Interests, hobbies, wish list, etc.

  20. Age of household member.

  21. Male or Female
  22. Interests, hobbies, wish list, etc.


  23. AUTHORIZATION TO USE AND EXCHANGE HOLIDAY ASSISTANCE INFORMATION

    I understand that multiple organizations may provide different services and benefits associated with my application for holiday assistance.  Each organization must have specific information to provide services and benefits.  By signing this form, I allow the organizations indicated below to use and exchange certain information about me, including information in an electronic database, so it will be easier for them to work together efficiently to provide or coordinate requested services or benefits. 

    I authorize New Kent Department of Social Services to use and disclose any information associated with the provision of Holiday Assistance to local churches, private social service and community organizations, the United Way, the Salvation Army to be able to use and exchange among themselves any and all assessment information, financial information and services needed ONLY for the purpose of service coordination and eligibility determination:

  24. I authorize release of information as stated above.*
  25. My relationship to the individual is:*
  26. Signature

    This authorization is good until my Holiday Assistance case is closed. I can withdraw this authorization at any time by telling the New Kent Department of Social Services.  The listed agencies must stop sharing information after they know my authorization has been withdrawn.  I have the right to know what information about me has been shared, and why, when, and with whom it was shared.  If I ask, each agency will show me this information.  I want all organizations to accept a copy of this form as valid authorization to share information.  If I do not sign this form, information will not be shared and I will have to contact each agency individually to give information about me that is needed.  However, I understand that treatment and services cannot be conditioned upon whether I sign this authorization. There is a potential for information disclosed pursuant to this authorization to be re-disclosed by the recipient and not be subject to the HIPAA Privacy Rule.

  27. Leave This Blank:

  28. This field is not part of the form submission.