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  • Welcome to Evergreen!

    Completion of this form is voluntary. It is your right to decline to provide any information you do not wish to disclose. Keep in mind that the more information you provide, the better we can connect you to the right services. By completing and signing this application, you are acknowledging that the information you’ve provided is true and correct to the best of your knowledge. Thank you for taking the time to complete this form and trusting us to serve you!
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  • Tennessen Warning

    Data Privacy Rights for Applicants/Recipients of Program Sponsored By Evergreen Youth & Family Services 

  • YOUR RIGHTS:

    Under the Minnesota Data Privacy Act, you have the right to know how the information you provide on the application for a program will be used. 

  • THE INFORMATION YOU PROVIDE WILL BE USED TO:

    Determine your eligibility for a specific program, which requires sharing information with other Evergreen Youth & Family Services employees. Information gathered will also assist us in identifying other community based resources you may be eligible for.

  • REFUSAL TO PROVIDE DATA: 

    You may refuse to provide the data.  This may prevent you from obtaining services from certain programs that require the data and our services to you may be limited.  You do not have to provide a Social Security Number to be eligible for our programs.  Federal Privacy Act and Freedom of Information Act dictate the use of the Social Security Number.  We may use it for computer matches, programs reviews and audits. We will ask you for your Social Security number for these purposes only and will not share that information unless dictated by law.

  • AUTHORIZATION BY LAW TO SHARE INFORMATION

    Evergreen Youth & Family Services is required bylaw to report aggregate statistical and demographic data on clients to state, federal and other federal monitors. Case files may be reviewed during required site visits.   With your informed consent, we may also share it with community agencies, local and state human service agencies, local government, educational programs, Minnesota Housing Financial Agency, DHS-OEO, DHS Adolescent Services, DHS Supportive Services, LTH, HUD, and other agencies that help you.  
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  • Statement on Mandated Reporting

  • Staff employed at the Evergreen Youth & Family Services are mandated by law to report all “firsthand” information regarding physical, sexual, and/or emotional abuse, as well as neglect of youth under the age of 18 to Beltrami County Human Services and/or the Law Enforcement Center. 

  • In the event an employeeof Evergreen suspects abuse, danger, and/or neglect, staff will:

    Complete an Evergreen Youth & Family Services Maltreatment of Minors Report describing the details and nature of the reported abuse and/or neglect.  

  • Forward the report within one business day to the intake worker at Beltrami County Human Services.

  • If the reported abuse constitutes imminent danger to a minor child, Evergreen staff will contact Beltrami County Law Enforcement Center.

  • If client reports abuse of child, unborn child,or vulnerable adult (developmentally disabled or elderly); staff will completea Maltreatment of Vulnerable Adults form.

  • If client declares that they are going to cause harm to themselves or another person Evergreen staff will contact Bemidji Law Enforcement Center immediately.
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  • Contact Information

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  • Demographic Information

    If you do not want to answer select "prefer not to disclose"




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  • Dependents

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  • Services Evergreen Provides

  • STAFF USE ONLY

  • External Referrals














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