Transcend STEM Community Action Intake & Consent Form

This application is for Community Service Block Grant (CSBG) assistance. The Community Service Block Grant provides assistance to States and local communities for the reduction of poverty, the revitalization of low-income communities, and the empowerment of low-income families and individuals to become fully self-sufficient (particularly families who are attempting to transition off a State program). The applicant/household must be at most 125% of the federal poverty guidelines in order to qualify for this funding.


*PLEASE COMPLETE INFORMATION TO THE BEST OF YOUR KNOWLEDGE*

APPLICANT

RentRent SubsidizedOwnWith Friends/FamilyHomeless

Hispanic or LatinNot Hispanic or Latin

MaleFemaleOther

YesNo

YesNo

AsianBlackHispanicNative AmericanPacific IslanderWhiteOther

NoYes: (see below)

PrivateMedicaidMedicareCHIPPCN

SingleSingle Parent/FemaleSingle Parent/MaleMarried (w/children)Married (no children)Single w/PartnerMultiple Adults (living w/children)Multiple Adults (no children)Grandparent (raising Grandchildren)Other

High School GradGED9th or less10th11th12th12+ (Post-Secondary) some collegeAssociate DegreeBachelor’s DegreeOther

YesNo

Un-EmployedFull TimePart-TimeSeasonal

$

WeeklyBi-MonthlyMonthlyAnnual/Seasonal

Source Amount in USD

Pay stubs (last 30 days)DIS (last 30 days)Employer Letter (last 30 days)SSI/SSD payment sheet

DOES ANYONE IN THE HOUSEHOLD HAVE?

YesNo

YesNo

YesNo

YesNo

NoYes, what & when?

OTHER

YesNoDon’t know

YesNoDon’t know

I, , give Transcend STEM Education consent to release, obtain, and share all pertinent identifying and non-confidential social, medical, and other information about myself that will allow me to benefit from services offered. In granting such permission, I understand that such information will remain confidential and that such information will only be used for my benefit or to benefit other members of my family. The statements made by me on this consent form are true, correct, and complete to the best of my knowledge."

By typing my name and submitting I consent that this constitutes my electronic signature and that I have read and understood the terms and conditions on this form and if I have made a payment for services referenced herein my signature serves as authorization to that payment.

In this section, please include ALL MEMBERS OF THE HOUSEHOLD

#1

Hispanic or LatinNot Hispanic or Latin

MaleFemaleOther

YesNo

YesNo

AsianBlackHispanicNative AmericanPacific IslanderWhiteOther

NoYes

PrivateMedicaidMedicareCHIPPCN

SingleSingle Parent/FemaleSingle Parent/MaleMarried (w/children)Married (no children)Single w/PartnerMultiple Adults (living w/children)Multiple Adults (no children)Grandparent (raising Grandchildren)Other

High School GradGED9th or less10th11th12th12+ (Post-Secondary) some collegeAssociate DegreeBachelor’s DegreeChild

YesNo

Un-EmployedFull TimePart-TimeSeasonal

$

WeeklyBi-MonthlyMonthlyAnnual/Seasonal

Additional Source Of Income

Source Amount in USD

Pay stubs (last 30 days)DIS (last 30 days)Employer Letter (last 30 days)SSI/SSD payment sheet

#2

Hispanic or LatinNot Hispanic or Latin

MaleFemaleOther

YesNo

YesNo

AsianBlackHispanicNative AmericanPacific IslanderWhiteOther

NoYes

PrivateMedicaidMedicareCHIPPCN

SingleSingle Parent/FemaleSingle Parent/MaleMarried (w/children)Married (no children)Single w/PartnerMultiple Adults (living w/children)Multiple Adults (no children)Grandparent (raising Grandchildren)Other

High School GradGED9th or less10th11th12th12+ (Post-Secondary) some collegeAssociate DegreeBachelor’s DegreeChild

YesNo

Un-EmployedFull TimePart-TimeSeasonal

$

WeeklyBi-MonthlyMonthlyAnnual/Seasonal

Additional Source Of Income

Source Amount in USD

Pay stubs (last 30 days)DIS (last 30 days)Employer Letter (last 30 days)SSI/SSD payment sheet

#3

Hispanic or LatinNot Hispanic or Latin

MaleFemaleOther

YesNo

YesNo

AsianBlackHispanicNative AmericanPacific IslanderWhiteOther

NoYes

PrivateMedicaidMedicareCHIPPCN

SingleSingle Parent/FemaleSingle Parent/MaleMarried (w/children)Married (no children)Single w/PartnerMultiple Adults (living w/children)Multiple Adults (no children)Grandparent (raising Grandchildren)Other

High School GradGED9th or less10th11th12th12+ (Post-Secondary) some collegeAssociate DegreeBachelor’s DegreeChild

YesNo

Un-EmployedFull TimePart-TimeSeasonal

$

WeeklyBi-MonthlyMonthlyAnnual/Seasonal

Additional Source Of Income

Source Amount in USD

Pay stubs (last 30 days)DIS (last 30 days)Employer Letter (last 30 days)SSI/SSD payment sheet

#4

Hispanic or LatinNot Hispanic or Latin

MaleFemaleOther

YesNo

YesNo

AsianBlackHispanicNative AmericanPacific IslanderWhiteOther

NoYes

PrivateMedicaidMedicareCHIPPCN

SingleSingle Parent/FemaleSingle Parent/MaleMarried (w/children)Married (no children)Single w/PartnerMultiple Adults (living w/children)Multiple Adults (no children)Grandparent (raising Grandchildren)Other

High School GradGED9th or less10th11th12th12+ (Post-Secondary) some collegeAssociate DegreeBachelor’s DegreeChild

YesNo

Un-EmployedFull TimePart-TimeSeasonal

$

WeeklyBi-MonthlyMonthlyAnnual/Seasonal

Additional Source Of Income

Source Amount in USD

Pay stubs (last 30 days)DIS (last 30 days)Employer Letter (last 30 days)SSI/SSD payment sheet

FOR ADDITIONAL HOUSEHOLD MEMBERS, PLEASE COMPLETE AN ADDITIONAL APPLICATION. YOU MUST LIST ALL FAMILY MEMBERS IN YOUR HOUSEHOLD AND THE INCOME OF ALL MEMBERS 18 OR OLDER.

SELF-SUFFICENCY STATEMENT

According to the Community Services Block Grant, "Self Sufficiency" is defined as: Achieving (or working towards) a set of goals which will result in greater self-sufficiency and the elimination some or all of the causes of poverty.

What issues is the applicant facing and what resources does the family need to address these issues?

What problems/concerns do you currently have, that if solved, would bring you (your family) out of poverty?

What community agencies are you currently working with?

What actions have you taken to address some of these problems/concerns on your own?

How have you started to implement your plans/goals?

How can you pay for the services for which you are seeking after our one-time services are rendered?

Below, please have a written plan toward self-support created within your family/household:

GAS VOUCHER/BUS PASS PROGRAM

YesNo

How will receiving transport assistance help you towards self-sufficiency

SCHOLARSHIP PROGRAM

Yes, please provide proof of the status on financial aid.No, why not?


HOUSING/RENTAL ASSISTANCE (does not cover mortgages. Contact Homeownership Made Easy for mortgage, closing costs or down payment assistance). 214-770-1252

YesNo

YesNo

NoYes, Amount $

YesNo


PROGRAM AGREEMENT

Case Management Agreement
I agree to participate in the Case Management Program offered by this agency and commit to completing the steps necessary to achieve my goals in order to improve my self-sufficiency. I understand that I need to be an active participant in services in order to achieve the goals that I establish. I also understand that members of my household will be active participants in Case Management Services.

I agree to contact my case manager, either by phone or email, as required and to meet at least once a month with my case manager.

I provide consent to my case manager to contact others service providers in order to coordinate the services.

I understand that failure to actively participate in the achievement of my goals may result in termination from the Case Management Program.
Authorization to Release Information

The Transcend STEM Education Program is designed to partner with other organizations which assist families experiencing a housing crisis, unemployment, career changes, needing education or other assistance. This authorization is to permit Transcend STEM Education and those organizations to share client information in order to collaborate on services and promote stability. By signing below you allow Transcend STEM Education to share (check ALL that apply)

Information to Be Released: Only authorized personnel will share client information needed for service delivery, program eligibility, to track demographic trends, service patterns and the client outcomes achieved. Non-personally identifying information may also be used for the purposes of research and reporting to other services agencies, current and potential program funding sources, and other programs offered by.

For the Purpose of: (a) providing coordinated housing, medical, social, psychological, and other services to me, (b) evaluating the outcomes related to service delivery, and (c) to improve coordination of services to assist individuals and families experiencing a crisis, and (d) to identify barriers and service gaps that block the path out of poverty. In the event of the publication of the results of the program, my identity will be kept confidential, although information about my circumstances may be discussed.

Right to Revoke: This authorization is subject to revocation at any time except to the extent that the agencies which are to make the disclosures have already taken action in reliance on those disclosures.

Potential Re-disclosure: In understand that information that I authorize to be disclosed may be re-disclosed and not subject to medical privacy regulations. However, federal confidentiality rules (42 CFR, part 2) prohibit recipients from making any further disclosure of alcohol and substance abuse records unless further disclosure is expressly permitted by written consent of the person to whom they pertain or if disclosure is otherwise permitted by 42 CFR, part 2. The Federal rules restrict any use of the information to criminally investigate or prosecute and alcohol or drug abuse client.

By signing below, I authorize Transcend STEM Education to share information as it relates to my specific needs.

Media Release Consent

PhotosMediaCrisis Information

By signing below, I authorize Transcend STEM Education to collect and share media information as it relates to my specific needs.