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DBA Consent

I, , give (NCWVCAA) consent to release, obtain, store and share all pertinent identifying and non-personally identifying social, medical and other information about myself or other members of my household that will allow me to benefit from services offered. In granting such permission, I understand that such information will be stored in a secure electronic data system. My information will remain confidential and that such information will only be used for my benefit or to benefit other members of my household. Only authorized personnel will share client information needed for service delivery, program eligibility, to track demographic trends, service patterns and the client outcomes achieved. Non-personally identifying information may also be used for the purposes of research and reporting to other service agencies, current and potential program funding sources and other programs offered by (NCWVCAA). I release (NCWVCAA) and its staff from any legal liability for disclosing or acquiring information that I have permitted by signing this form. Unless I make a formal request to (NCWVCAA) that I no longer want to participate in the services offered, this release will remain in force indefinitely as of today. The statements made by me on this consent form are true, correct and complete to the best of my knowledge as of the date signed.

North Central West Virginia Community Action Association, Inc., its agent, partners and funding sources do not discriminate on the basis of race, color, sex, religion, national origin, disability or marital status.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

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January 14, 2019 2:18 am EDT

DBA Consent Uploaded by Rob Everly - itadmin@ncwvcaa.org IP 147.0.246.114