Which Project Connect will you attend? Winchester Project Connect: June 7th at Charlotte DeHart School, 9 am a 3 pm Woodstock Project Connect: June 28th, 9 am a 3 pm. Contact Information First Name Last Name Email? Primary Phone City Zip Code What language do you speak? English Espanol Other… Enter other… Date of Birth Gender Male Female Race Black/African American White Asian American Indian/Alaska Native Native Hawaiian/Pacific Islander Multi-Race Prefer not to say Marital Status Single Married Prefer not to say How many people live in your household? Do you have children under 18 living in your household? Yes No If yes, how many? What is your current employment status Employed full time Employed part-time Unemployed and currently looking for work Unemployed and NOT currently looking for work Student Retired Disabled/Unable to work Have you ever served in the U.S. military? Yes No Prefiero no responder Do you consider yourself homeless? Yes No Please check ALL services you are interested in receiving at Project Connect: Some services require advanced registration (DMV and Heart Attack Risk Screenings). If you register for one of these services, someone will call you to schedule an appointment. Please note: some service are in high demand and no service is guaranteed. MEDICAL and DENTAL SERVICES Vision and Hearing screenings Dental screening Blood pressure screening Healthy eating/nutrition Insurance and Medicaid enrollment Finding a doctor Valley Health financial assistance Prescription medication assistance HIV testing Deaf and hard of hearing assistance MENTAL HEALTH and SUBSTANCE ABUSE SERVICES Depression and substance abuse screenings Treatment options Connect with Certified Peer Recovery Specialists Addiction/Substance Use Resources HOUSING and SHELTER SERVICES Homeless and Housing assessments Utility Assistance, Rental Assistance Rental Assistance Shelter Information Home ownership opportunities Home repair programs BASIC NEEDS SERVICES Haircuts Clothing Food EMPLOYMENT SERVICES Job training programs Building a resume Help searching for a job Jobs for people with disabilities 55+ employment opportunities Youth employment programs GED/ adult education VETERAN SERVICES Veterans employment services Housing for veterans Getting copy of DD-214 Other resources for Veterans LLEGAL – 1-on-1 consultations services (not criminal): Debt collection Benefits (disability) Landlord/Tenant Issues Domestic violence Family law CHILDREN and FAMILY SERVICES Transportation Domestic violence resources Computer classes Citizenship services Sign-up for CCAP services Childcare resources Parenting resources Library services Theraputic horesback riding program Theraputic running program for girls BANKING and MONEY MANAGEMENT SERVICES Free checking accounts Financial checkup/budgeting information Credit report check I agree to the terms of service Release of Information and Disclaimer Regarding Services The Valley Assistance Network and Project Connect are resource and referral systems developed by United Way of Northern Shenandoah Valley to help individuals and families connect with available community resources, navigate barriers, and provide the tools needed to move from crisis to financial security. I understand that all information gathered about me is personal and private and that I do not have to participate in this program. I also understand that information about non-confidential services provided to me by partner agencies may be shared with other agencies. This Release of Information will remain in effect for 3 years from the date noted under my signature at the bottom of this page unless I make a formal request to this organization that I no longer wish to participate in the program. I authorize United Way of Northern Shenandoah Valley, coordinator of the Valley Assistance Network (VAN) and Project Connect, to share my basic, identifying and non-confidential service transactions/information with other agencies on my behalf. I further authorize the above agency to share my basic, identifying and non-confidential service transactions/information with other participating agencies. My signature below authorizes Valley Assistance Network to disclose my personal information to partner agencies with the sole purpose of coordinating services to better serve me and my family. I further authorize disclosure of my personal information (including any health information) to any person or organization that the agency deems necessary to resolve my emergency. The material released to a third party will be directly related to the assistance that is being provided to me, as a client. This may include, but is not limited to, landlords, utility companies, household members, current or former employers and churches. The purpose of this authorization is to allow the agencies to provide information and answer pertinent questions to resolve my emergency. United Way's Valley Assistance Network and Project Connect volunteers make referrals and contacts to the best of their ability to assist clients with their needs, and these referrals are made in good faith. However, I acknowledge that Valley Assistance Network, Project Connect, and the partner agencies participating in Project Connect, cannot guarantee any services from any referrals, contacts, or conversations. Nor do I hold Valley Assistance Network, Project Connect or any partner agency responsible for any negative situation, including cost or personal harm, that may arise coincidentally from such referrals. I agree that I am undertaking the services from Project Connect at my own risk and will not hold United Way NSV or partner agencies and businesses liable. Photo Release. Participants hereby authorize the United Way the use of photographs for United Way publications. Participants acknowledge that the use of photos is voluntary and that no financial compensation or ownership rights are expected Signature Reset SUBMIT
