I understand that the St. Vincent de Paul Society of St. Joseph County, Inc. (SVDP), may need to obtain and/or share information about me to establish my eligibility for services such as client choice pantry, home food delivery, food and clothing vouchers, rent and utility assistance, and any other SVDP program for which I apply.  I also understand that SVDP may obtain and/or share information about me through written, oral, and electronic communication.

By submitting this form:

• I authorize SVDP to obtain information about me from other agencies, organizations, and individuals for the limited purpose of making decisions about my eligibility for and participation in one or more SVDP programs.
• I authorize SVDP to share information about me from other agencies, organizations, and individuals for the limited purpose of making decisions about my eligibility for and participation in one or more SVDP programs.
• I authorize SVDP to release information about me, the services I receive and their value for purposes of qualification of me or my household for external agency programs, housing, assistance, or other services.
• I understand that my authorization will remain effective from the date I sign below until I withdraw this authorization in writing.
• I understand that I may withdraw this authorization at any time by delivering a written notice to the Executive Director of SVDP, and that my withdrawal will be effective when SVDP receives it.
• I understand that SVDP will handle my personal information in compliance with all applicable state and federal laws.