Release of Information and Disclaimer Regarding Services
The Valley Assistance Network (VAN) is a resource and referral system developed by United Way of Northern Shenandoah Valley (UWNSV) 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 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 makes these referrals and contacts to the best of the ability to assist clients in their emergency needs, and these referrals are made in good faith. However, I acknowledge that Valley Assistance Network cannot guarantee any services from any of our referrals or contacts. Nor do I hold Valley Assistance Network responsible for any negative situation, including cost or personal harm, that may arise coincidentally from such referrals.