Pardon Project - Intake Packet

INTAKE PACKET
Staff Completing Intake:
Intake Date*

MonthDayYear
Staff Email Address

EMERGENCY CONTACT INFORMATION
Name*

First NameLast Name
Relationship To Client*
Phone Number*
Please enter a valid phone number.
EMPLOYMENT
Current Employment Status*

Employed full-time (32+ hours per week)Employed part-time (Less than 32 hours per week)UnemployedDisabled / Unable to work
Name of Employer*
Location / Address*
Current Job Title / Role*
Start Date*
Previous Employment History*
Include place(s) of employment, date ranges, job titles, etc.

INCOME QUALIFICATION / VERIFICATION STATEMENT
Annual Income*
Provide the total gross (before taxes) annual income of all members currently living in the home.
Monthly Income
Generated automatically from annual income.
Weekly Income
Generated automatically from annual income.
Hourly Rate
Generated automatically from annual income based on a 40 hour work week.
# of Family Members*
Poverty Guideline*
Generated automatically based on # of family members.
Percentage of Poverty Level
(CALCULATION EXPLANATION: Calculation of the percentage of poverty level is determined by dividing the income by the poverty guideline and multiplying by 100.)
Federal Poverty Level (FPL)
Please provide verification of your income (ex: paystub, most recently filed income taxes, SSI / SSD statement, etc) IF YOU'RE UNABLE TO UPLOAD YOUR PROOF OF INCOME, IT IS YOUR RESPONSIBILITY TO EMAIL / TEXT A COPY TO THE PROGRAM DIRECTOR EMILY BALMER (pardonmeyork@strivepa.com or 717-238-9950)

Cancelof
FRAUD DISCLAIMER: I hereby verify that the facts set forth herein are true and correct to the best of my personal knowledge or information and belief, and that any false statements herein are made subject to the penalties of: Pennsylvania CRIMES CODE Title 18 SECTIONS: (4903 FALSE SWEARING), (4904 UNSWORN FALSIFICATION) and (4911 TAMPERING WITH PUBLIC RECORDS OR INFORMATION). VIOLATIONS OF THESE SECTIONS ARE SUBJECTED TO PUNISHMENT OF A FINE NOT EXCEEDING $5,000 OR TO TERM OR IMPRISONMENT OF NOT MORE THEN TWO (2) YEARS, OR BOTH.
Signature:*

Clear
Date:*

MonthDayYear

RELEASE OF INFORMATION
Client Name*

First NameLast Name
Types of Records Requested:*

General RecordsOther
I hereby give my consent for:
To release information to:
I hereby authorize the above-named source to release or disclose information related to the above-referenced records / information to the requester for a period of 365 days beginning on the date this document was signed by client.

The information being requested is: any and all information pertaining to all criminal charges in York County

Authorization for disclosure is being given for the purpose of: coordination of reentry services and continuity of care.

In authorizing this disclosure, I explicitly waive any and all rights I may have to the confidential maintenance of these records, including any such rights that exist under local, state, and federal statutory and / or constitutional law, rule or order.

I understand that I have no obligation to permit disclosure of any information from my record and that I may revoke this authorization, except to the extent that action has already been taken, at any time by notifying the Program Director or CEO. In any event, this authorization will expire 365 days after the date signed, unless revoked prior to that time.

It is understood by the above requester that if the requested information’s confidentiality is protected by Federal Regulations that bar secondary dissemination or re-disclosure, the providing facility will provide a statement to that effect.

Furthermore, I will indemnify and hold harmless STRIVE Initiatives, and its employees and agents, for any losses, costs, damages, or expenses incurred because of releasing information in accordance with this authorization.
Client Name

First NameLast Name
Client Signature*

Clear
Date*

MonthDayYear
Date
Client was offered a copy of this Authorization for Release of Information and*

Accepted a copyRefused a copy

RELEASE OF INFORMATION
Client Name

First NameLast Name
I hereby authorize The Pardon Project of York County / STRIVE Initiatives to release or disclose information related to the above-referenced records / information to the participating agencies for a period of 365 days beginning on the date this document was signed by client.

The information being requested is: any and all information pertaining to all criminal charges in York County

Authorization for disclosure is being given for the purpose of: coordination of reentry services and continuity of care, Pardon

In authorizing this disclosure, I explicitly waive any and all rights I may have to the confidential maintenance of these records, including any such rights that exist under local, state, and federal statutory and / or constitutional law, rule or order.

I understand that I have no obligation to permit disclosure of any information from my record and that I may revoke this authorization, except to the extent that action has already been taken, at any time by notifying the Director of Operations or CEO. In any event, this authorization will expire 365 days after the date signed, unless revoked prior to that time.

It is understood by the above requester that if the requested information’s confidentiality is protected by Federal Regulations that bar secondary dissemination or re-disclosure, the providing facility will provide a statement to that effect.

Furthermore, I will indemnify and hold harmless STRIVE Initiatives and The Pardon Project of York County, and its employees and agents, for any losses, costs, damages, or expenses incurred because of releasing information in accordance with this authorization.

Participating Agencies
- The York County Bar Association
- Volunteer Pardon Coaches
- The York County Pardon Project Board
Client Name*

First NameLast Name
Client Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

	First and Last Name	Date of Birth	Gender	Ethnicity	Race	If this is a minor child, do you have legal custody or guardianship of the child?
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	Yes	No	If yes, when?
TANF Child Care Services
TANF Transportation
Other TANF Funded Services
Section 8, Public Housing or Other Ongoing Rental Assistance
Temporary Rental Assistance
Other Source

	Whose Income?	Income Source	Amount / How Many Times Per Month	Date Started
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INTAKE PACKET

CLIENT INFORMATION

EMERGENCY CONTACT INFORMATION

EMPLOYMENT

HOUSEHOLD MEMBERS

HOUSEHOLD FINANCIAL RESOURCES

CRIMINAL BACKGROUND

INCOME QUALIFICATION / VERIFICATION STATEMENT

RELEASE OF INFORMATION

RELEASE OF INFORMATION