By signing this authorization, I grant permission for the sharing of information which is to be used to determine eligibility for participation in the Community Services Block Grant (CSBG) or other agency programs under the umbrella of Community Action as operated by the Miami Valley Community Action Partnership for either myself or my family members.
I understand this release will terminate one year from the date I sign this authorization or sooner if I request so in writing.
I understand that all information obtained in association with this release will be held in strict confidence by the recipient.
I further direct that information shared resulting from my signature not be further disclosed without my specific written authorization.
I further declare that I understand and permit an information exchange strictly for disclosure purposes related to Miami Valley Community Action Partnership programming.
I also hereby give permission to release to and /or secure information from the following organizations for the purpose of securing services I have requested: