I have read this consent form (or it has been read to me) and I understand the information it provides. I agree to take part in the "UN-Repeating the Cycle" Program and to participate in the program services. The funding for this program is made possible by a grant from the Office of Juvenile Justice Delinquency Prevention. The information on this form is for record keeping requirements for our federal grant reporting. This information is archived and stored in a secure electronic location.
Privacy Act Statement
Pursuant to the Amended Privacy Act of 1974, failure to provide your SSN will not make you ineligible for admission into the program. Furnishing us this information is voluntary. However, failure to provide your SSN will make you ineligible for bill pay assistance. You can provide a copy of a recent check stub, benefits statement, tax form or drivers license as proof that you have a SSN. This information can be uploaded to the form or provided at a later time to the case manager. We will use the information that you provide to satisfy reporting requirements as requested by the Office of Juvenile Justice Delinquency Prevention and to justify paying benefits through our bill pay assistance program. The information collected from this form will be housed in a secure electronic location and will not be shared with any other organizations outside of our federal grantor.
This organization often advocates on behalf of the participants. I understand that if I request assistance with advocacy that I will be required to sign a seperate authorization giving permission for this organization to advocate on my behalf.
If I have questions, I can call Amber Govan, Project Director for "UN-Repeating the Cycle" at 501-618-0996. I can also call Lahairoi Collins, Director of Community Outreach at 501-502-5572.