Project Connect Client Registration

Please complete this form to register for Project Connect.

Contact Information
Gender
Race
Do you have children under 18?
Employment (What is your current employment status?)
Have you ever served in the U.S. Military?
Did you lose a job or lose income due to COVID-19?
Do you consider yourself homeless?
Event options:
At Project Connect, participants can be paired with a guide – a volunteer to help you visit the tables and make sure you are able to access all of the resources.  Please check one:
 
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 & DENTAL SERVICES
Vision and Hearing screenings
Dental screening
Heart Attack Risk Screening (Appointment Required)
Blood pressure screening
COVID-19 vaccine
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 & SUBSTANCE ABUSE
Depression and substance abuse screenings
Treatment options
Connect with Certified Peer Recovery Specialists
Addiction/Substance Use Resources
BENEFITS & VITAL RECORDS
Get an ID or other DMV services (Appointment Required)
Apply for Birth certificate
Apply for Social Security card
Apply for Medicaid
Voter Registration
HOUSING AND SHELTER INFORMATION
Homeless and Housing assessments (Centralized Housing Intake)
Rental Assistance
Utility Assistance
Shelter Information
Home ownership opportunities
Home repair programs
BASIC NEEDS
Haircuts
Clothing
Food box
EMPLOYMENT
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
On-the-spot job interviews
VETERAN’S SERVICES
Veterans employment services
Housing for veterans
Getting copy of DD-214
Other resources for Veterans
CHILDREN AND FAMILY SERVICES
Transportation
Children/Family resources
Domestic violence resources
Computer classes
Citizenship services
Park and Recreation programs
Free museum visits
Sign-up for Bright Futures services
Sign-up for CCAP services
Childcare resources
Parenting resources
Library services
BANKING AND MONEY MANAGEMENT
Free checking accounts
Financial checkup/budgeting information
Credit report check
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.

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.



 

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