The Gordon County Community Services Network, hereinafter referred to as “GCCS Network”, is a shared, internet based record keeping system that records and stores information about emergency services provided, including but not limited to utility assistance, food, medication, rent/mortgage assistance, etc. The Voluntary Action Center serves as the administration of the GCCS Network on behalf of Member Organizations.
I understand that all information gathered about me is private and that participation is voluntary. I have had an opportunity to review this form and understand that the information collected regarding my assistance records is accessible by GCCS Network Members.
This Release of information will remain in effect for three (3) years from the date noted by my signature at the bottom of this page unless I make a written request to this Organization to be removed from the GCCS Network.
I authorize the Voluntary Action Center, as a GCCS Network Member, to share my identifying information as well as assistance information, including denial of service within the GCCS Network. I also authorize GCCS Network Members to make referrals to appropriate service providers, in an effort to implement service plans. I understand that such service may include health, educational, psychological, nutritional, housing, financial, employment, and other services which may apply. I understand that this information will be kept confidential by GCCS Network Members, unless required by law, as in situations such as child abuse or threats of harm to self and others. In no instance, other in such required reports, will this information be provided to individuals or agencies that are not a part of this process.
I hereby authorize Voluntary Action Center to request information regarding education, income, medical, household composition, family services received, and psychological information as required to determine eligibility as well as services provided. I understand that I must submit all information and forms requested by the Voluntary Action Center before my application will be considered for aid.
I understand that by submitting an application for aid, I, and other members of my household, may have various assessments completed by the Voluntary Action Center staff, and agree to be an active participant in the implementation of the resulting service plans. My signature below indicates my agreement for all individuals living in my home as listed on the back of this document, to participate in the process, as well. It is my understanding that I may withdraw from participation at any time.