As an applicant, I consent to release, obtain and share all pertinent identifying and non-personally identifying social, educational, 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 remain confidential and that such information will only be used for my benefit or to benefit other members of my household. I understand that such information will be stored securely. 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 a network of partners. I release the First State Community Action Agency, Inc. and their staff from any legal liability for disclosing or acquiring information that I have permitted by checking the above box. Unless I make a formal request to First State Community Action Agency 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 site are true, correct and complete to the best of my knowledge as of the date submitted.