FFT Intake Complete Enrollment Packet

Credit Release Authorization
To assist Edna Martin Christian Center in its ability to provide me with financial counseling services, I hereby authorize Edna Martin Christian Center to pull my Transunion credit report and FICO score now and periodically, but not more frequently than once every six (6) months for a period not to exceed five (5) years from the date of this authorization. I understand that all inquiries by Edna Martin Christian Center into my credit constitute "soft inquiries" and will not adversely affect my credit or my credit rating. While the credit reports and scores pulled by Edna Martin Christian Center on my behalf will be used to provide me with financial counseling and/ or to track my financial outcomes, it is understood that I will not receive a copy of the credit reports. I understand that I may request a financial counseling session at Edna Martin Christian Center in the future to discuss information in any credit report and/or credit score pulled by Edna Martin Christian Center on my behalf I further understand that I may withdraw Edna Martin Christian Center's authorization to pull additional credit reports or credit scores at any time without penalty. Notwithstanding the foregoing, I understand that I have the right to dispute information with the credit bureau, to request reinvestigation, and to have corrected reports reissued to previous recipients of the credit report at issue.
I understand that credit information is sensitive and that there may be inherent risks to accessing such data; I have had the opportunity to ask My Financial Counselor questions regarding such risks. I understand that all of my personal information will be held confidential by Edna Martin Christian Center and used only as authorized by me.
Any questions that I may have regarding the above will be answered by a Center for Working Families Counselor at Edna Martin Christian Center. 

CERTIFICATION AND AUTHORIZATION FOR RELEASE OF INFORMATION
"I certify that the information provided is correct and true to the best of my knowledge. I also understand that I may be required to verify these statements and give my consent to Edna Martin Christian Center to make necessary contacts to verify these statements. I consent to the release of any information for this purpose. I understand that I will be held responsible if I have provided false or fraudulent information to obtain services from this agency."

APPEAL INFORMATION
If you are denied and do not agree with the reason stated, you may appeal the decision to the Edna Martin Christian Center Board of Directors.

Edna Martin Christian Center helps participants become more financially secure by assisting them to get and keep jobs, enter and complete training, access public benefits for which they are eligible, and learn how to manage their money. Edna Martin Christian Center is working with Local Initiatives Support Corporation ("LISC") to figure out which kinds of assistance and supports are helpful to participants and which ones are not. The information you provide us during your participation in this program will be compiled with other people s data and shared, with USC to help provide better service to participants.
Your Right to Confidentiality
The information you provide to Edna Martin Christian Center, and LISC is completely confidential. In research reports and presentations, your privacy will always be respected and your name or other personal information that might identify you will be disclosed to the public or sold for commercial purposes.
Benefits and Risks
There are no special benefits or risks to you as an individual if you participate in this research; the information " will be used only for learning purposes, so that programs know the kinds of assistance and support that help people become more financially secure. Participation in this reseanh study is completely voluntary. If you do not want to pruticipate in the research, you may still continue to receive the same services and supports. Also, if you choose to participate in the research you may discontinue participation at any time without penalty.

1. I give and grant in perpetuity to Local Initiatives Support Corporation, its affiliates and subsidiaries ("USC"), and their respective representatives, agents, licensees, successors and assigns (herein collectively called "Licensed Parties") an unconditional, nonexclusive, worldvide, royalty-free, irrevocable license and right to use my name, image, biographical infonnation, performance, voice, photograph and likeness (collectively, "Image Rights") in all media and content whether now existing or later discovered or invented, prepared for or by the Licensed Parties for any and all types of advertising, publicity, marketing, promotion, exhibition and other purpose that is connected to USC's charitable mission.
2. I agree that any materials taken, developed, produced, created, or derived therefrom by the Licensed Parties (collectively, the "Materials") that contain my Image Rights are owned by the Licensed Parties and that they may copyright such Materials. I will not authorize any other person, firm or entity to use such Materials or take any action inconsistent with the rights and license granted to the Licensed Parties.
3. I agree that no Materials need to be submitted to me for any further approval, and the Licensed Parties shall have no liability to me or anyone else for any distortion, illusionary effect or otherwise resulting from the use of my Image Rights.
4. I warrant and represent that (i) I am of legal age in the state in which I reside; (ii) I have the full right and authority to enter into this Photo and Video Release ("Release") and grant the license and rights described herein; and (iii) this Release does not in any way conflict with any existing commitment on my part.
5. Everything contained in this Release is and shall be binding on me, my agents, heirs, successors, assigns and representatives. I hereby release and hold the Licensed Parties harmless from and against any and all losses, claims (including without limitation any and all claims for libel or violation of any right of publicity or privacy), actions, damages, liability, costs and expenses arising out of this Release and the use of the Image Rights by the Licensed Parties. Nothing herein will constitute any obligation on the Licensed Parties to make use of the Image Rights.