EmailMe Form - COVID 19 Assistance Application

Name *

First Middle Last

Date of Birth

MM / DD / YYYY

Social Security Number *

Form of Identification * *

Driver's license, State ID, Birth Certificate, Social Security Card that matches the applicant's name.

Phone *

### - ### - ####

Email

Your Current Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

County *

Gender *

Male

Female

Other

Disabled *

Yes

No

SNAP (Food Stamps) *

Yes

No

Race *

Education *

Ethnicity *

Hispanic, Latino or Spanish Origins

Non Hispanic, Latino or Spanish Origins

HOUSEHOLD INFORMATION

Number In Household
(Including Yourself) *

Additional Family Members

If there are other family members living with you, you can list their info later when a Bridges specialist contacts you.

Family Type *

Work Status
(check all that apply) *

Health Insurance Type *

Source(s) of Income
(Check All That Apply For the Last 30 Days) *

Income Amount
(Last 90 Days) *

Has COVID-19 caused your household to lose income since March 1, 2020? *

Yes

No

AUTHORIZATION FOR INFORMATION EXCHANGE

By signing this authorization, I grant permission for the sharing of information which is to be used to determine eligibility for participation in the Community Services Block Grant (CSBG) or other agency programs under the umbrella of Community Action as operated by the Bridges Community Action Partnership for either myself or my family members.

I understand this release will terminate one year from the date I sign this authorization or sooner if I request so in writing.

I understand that all information obtained in association with this release will be held in strict confidence by the recipient.

I further direct that information shared resulting from my signature not be further disclosed without my specific written authorization.

I further declare that I understand and permit an information exchange strictly for disclosure purposes related to Bridges Community Action Partnership programming.

I also hereby give permission to release to and /or secure information from the following organizations for the purpose of securing services I have requested:

LIST ORGANIZATIONS

Today's Date *

MM / DD / YYYY

I certify that this statement is true and correct to the best of my knowledge, and I authorize the release of any or all information necessary for verification process. *

I agree to the terms & conditions

Click above if you have read and agree to the Terms & Conditions

I have read privacy terms *