CONSENT and RELEASE FORM
1) When you apply at the United Way of Gaston County 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 your 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, Gaston County Dept. of Health and Human Services, the Salvation Army, Crisis Assistance Ministries, and area churches.
3) In order to help you, we may also need to contact your landlord, mortgage holder, utility company, Oil Company, employer, 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 the United Way to verify your situation. By signing below, you give us permission to share information in your file with that church or organization.
5) I understand that by signing below, I am giving the United Way of Gaston County permission to obtain information pertaining to my household from the Gaston County Department of Health and Human Services.
6) The United Way reserves the right to refuse its services (both now and in the future) to anyone under or appearing to be under the influence of alcohol and /or drugs, displaying a rude and/or threatening behavior or to any person who gives false, fraudulent, or misleading information to the United Way for the purpose of obtaining assistance.
7) I certify that all information submitted/provided on this application is correct, to the best of my knowledge.
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, the United Way cannot help you.
This Consent and Release Form is valid for two years from the last date signed. If you wish to revoke this consent and release, please contact our office.
*I authorize the United Way to provide information to the above stated agencies and resources for the purpose of verifying information, determining the amounts required, committing funds, and paying bills in order to act on my application and in response to other organizations which I have approached for help.