Office Use Only

OFFICE USE ONLY: NEW UPDATE REQUESTING: FOOD FINANCIAL OTHER ______- ______

Application for Assistance Date ______

Name: ______[ ] Male [ ] Female (First) (Last) (Maiden) Date of Birth: ______Social Security #: ______-______-______Marital Status:______Hispanic: [ ] Yes [ ] No Race: [ ] White [ ] African Am [ ] Asian [ ] Native Am [ ] Multi Languages______Name of Employer:______Date of Hire: ______Position:______If Not Employed: Unemployed Since: ______Last Employer______Last Position Held______Veteran: [ ] Yes [ ] No Disabled? [ ] Yes [ ] No

Homeless: [ ] Yes [ ] No How long have you been homeless? ______

Address: ______Apt # ______Phone#______City ______, GA Zip ______County______Email:______Neighborhood/Apt Complex Name:______Phone #:______Landlord/Lessor Name:______Phone # ______Move in Date:______Rent/Mortgage check payable to: ______

Spouses Name: ______[ ] Male [ ] Female (First) (Last) (Maiden) Date of Birth: ______Social Security #: ______-______-______Hispanic? [ ] Yes [ ] No Race: [ ] White [ ] African American [ ] Asian [ ] Native American [ ] Other Language(s):______Name of Employer:______Date of Hire: ______Position:______If Not Employed: Unemployed Since: ______Last Employer______Last Position Held______Veteran: [ ] Yes [ ] No Disabled? [ ] Yes [ ] No  Names of children/dependents living with you Gender Date of Birth Relationship Race HSP? Y/N ______M / F ______M / F ______M / F ______M / F ______M / F ______M / F ______ OTHER THAN those listed above, list other (adults 18 & older) that are living with you: ______M / F ______M / F ______M / F ______

TOTAL NUMBER OF PEOPLE LIVING AT CURRENT ADDRESS: ______( # of Adults______# of Children______) EMERGENCY CONTACT: ______TELEPHONE #:______RELATION:______

PW Check#______ALL monthly EXPENSES that Type apply ______to you : Amount______Date______Living: [ ] Mortgage/Rent [ ] Home Insurance [ ] Electricity [ ] Heating [ ] Water [ ] Cable/Internet [ ] Phone [ ] Food Transportation: [ ] Bus [ ] Taxi [ ] Car [ ] Car Insurance [ ] Gasoline Medical: [ ] Prescriptions [ ] Insurance [ ] Bills [ ] Childcare [ ] Prenatal care Due Date______ Check ALL monthly INCOME that apply to you : Employment: [ ] Salary [ ] Spouse [ ] Roommate/Other [ ] Pension [ ] Worker’s Comp. [ ] Child Support Benefits: [ ] Unemployment [ ] SS [ ] SSI [ ] SSDI [ ] TANF [ ] Food Stamps [ ] Medicaid [ ] WIC

BEFORE SIGNING APPLICATION BELOW PLEASE BE SURE TO COMPLETE ALL ITEMS; FAILURE TO DO SO MAY DELAY PROVISION OF SERVICES.

NFCC RELEASE AND WAIVER OF LIABILITY APPLICANT This Release and Waiver of Liability (the “Release”) sets forth certain terms and respect to Applicant’s request for certain assistance and services and is executed in favor of North Fulton Community Charities, a nonprofit corporation, it’s directors, officers, employees, volunteers, agents, successors and assigns (collectively, ‘NFCC’). Applicant desires for NFCC to provide certain assistance and services. Applicant’s signature below indicates Applicant’s acknowledgement and agreement, without duress, to the following terms: WAIVER AND RELEASE. Applicant does hereby release forever discharge and hold harmless NFCC from and all liability, claims and demands of whatever kind, either in law or in equity, which arise or may hereafter arise from NFCC’s activities for or on behalf of Applicant. Applicant understands and acknowledges that this Release discharges NFCC from any liability or claim that the Applicant may have against NFCC that may result from NFCC’s activities for or on behalf of Applicant and/or Applicant’s minor children, if applicable whether caused in whole or in part by Applicant’s negligence or the negligence of NFCC. ASSUMPTION OF RISK. Applicant understands that the food NFCC distributes is donated to NFCC by third parties. In connection thereto, Applicant assumes all risk of accepting and consuming such food and releases NFCC from all liability resulting from the consumption of such food. DISCLOSURE OF INFORMATION. Applicant understands and agrees that all personal information provided by Applicant to NFCC, whether provided through the Application for Assistance, through other written communication or verbally, may be shared with third party service providers that conduct activities related to the type of assistance and services provided by NFCC. OTHER. Applicant expressly agrees that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Georgia, and that this Release shall be governed by and interpreted in accordance with the laws of the State of Georgia. Applicant agrees that in the event that any portion of the release is held to be invalid, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this release which shall continue to be enforceable. IN WITNESS WHEREOF, Applicant has read and voluntarily signed this Release, and further agrees that no oral representations, statements, or inducements apaprt from the foregoing written agreement have been made.

______Signature Spouse/Roommate Date

PATHWAYS CLIENT AUTHORIZATION FORM

I understand that North Fulton Community Charities is part of the Pathways Community Network. This agency has my permission to obtain any information regarding me in the Pathways system and to enter in the system information. I supply to this agency concerning my situation and my need for assistance. I understand that agencies in the Pathways system will keep this information confidential, and that another agency will only be able to view this information if I give permission. I also understand that staff at each participating agency is required to receive regular training on client confidentiality and social services best practices’ issues.

______Signature Printed Name Date