I.M.P.A.C.T. Housing Resource Intake Registration

I.M.P.A.C.T. Client Registration
Intake Date

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Gender*
Social Security Number
Primary Language*
Number of adults in your household?*
Number of children in your household?*

Emergency Contact Information
Name of Emergency Contact #1*

First NameLast Name
Phone Number of Emergency Contact*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number of Emergency Contact
Please enter a valid phone number.Format: (000) 000-0000.
Relationship of Emergency Contact*
Email of Emergency Contact
example@example.com
Address of Emergency Contact

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Emergency Contact #2

First NameLast Name
Phone Number of Emergency Contact
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number of Emergency Contact
Please enter a valid phone number.Format: (000) 000-0000.
Relationship of Emergency Contact
Email of Emergency Contact
Address of Emergency Contact

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list any allergies to food, medications or others and your reactions

HOLD HARMLESS AGREEMENT

The purpose of this agreement is to outline the terms under which both parties agree to indemnify and hold each other harmless from any claims, damages, liabilities, or expenses arising from participating in the I.M.P.A.C.T. Program at the Police Athletic League of Wilmington

Below are the key provisions of the hold harmless agreement:

Indemnification: Each party agrees to indemnify and hold harmless the other party, its officers, directors, employees, agents, and representatives from and against any and all claims, liabilities, damages, losses, costs, and expenses, including but not limited to attorney fees, arising out of or related to participating in the I.M.P.A.C.T. Program at the Police Athletic League of Wilmington.

Limitation of Liability: The parties agree that their liability under this agreement shall be limited to the length of time actively enrolled and participating in the I.M.P.A.C.T. Program.

Governing Law: This agreement shall be governed by and construed in accordance with the laws of the State of Delaware.

Entire Agreement: This agreement constitutes the entire understanding between the parties concerning the subject matter herein and supersedes all prior agreements and understandings, whether written or oral, relating to such subject matter.

Effective Date and Termination: This agreement shall become effective as of the date of signing and shall remain in effect until the client becomes inactive for a period of six months or the is client voluntarily or involuntarily unenrolled from the program.

*By signing below, I hereby agree to the terms and conditions of this Hold Harmless Agreement.
Signature*
Date*

MonthDayYear
Date

Participation Policy

Voluntary Participation: Participation in the I.M.P.A.C.T. Program is entirely voluntary. Individuals are under no obligation to participate, and they may choose to withdraw from the program at any time without consequence. However, please note that if you voluntarily withdraw or do not fulfill the requirements of the program, you may become ineligible to continue receiving services.

Informed Consent: Before participating in the program, individuals will receive detailed information about the program objectives, activities, potential risks, and benefits. Participants will be required to provide their informed consent to participate, indicating that they understand the nature of the program and agree to voluntarily take part.

Confidentiality: We are committed to maintaining the confidentiality of participants' personal information and any data collected during the program. Participants' privacy will be respected at all times, and their information will only be used for program-related purposes, as outlined in our privacy policy.

Rights of Participants: Participants have the right to ask questions, seek clarification, and express any concerns they may have about the program. We encourage open communication and will address any participant concerns promptly and respectfully.

No Coercion or Discrimination: Participants will not be subjected to coercion, intimidation, or discrimination based on their decision to participate or not participate in the program. All individuals will be treated with fairness, dignity, and respect, regardless of their participation status.

Feedback and Evaluation: We value participants' feedback and will regularly seek input to evaluate and improve the program. Participants will have the opportunity to provide feedback on their experiences, suggest improvements, and contribute to program development.

*By signing below, you acknowledge that you have read and understood the voluntary participation policy for the I.M.P.A.C.T. Program. If you have any questions or require further information, please do not hesitate to contact us.
Signature*
Date*

MonthDayYear
Date

Data Collection Policy

Purpose of Data Collection: The primary purpose of collecting data is to track participation in the I.M.P.A.C.T. Program, improve services, conduct research, track program outputs and comply with legal regulations.

Types of Data Collected: We may collect various types of data, including but not limited to:

Personal information (e.g., name, address, contact details)
Demographic information (e.g., age, gender, ethnicity)
Transactional data (e.g., purchases, donations)
Usage data (e.g., website visits, interactions with our services)
Any other relevant information necessary for fulfilling the intended purpose of data collection.

Data Collection Methods: Data may be collected through various channels, including:

Online forms and surveys
In-person interactions
Phone calls or emails
Automated technologies (e.g., cookies, tracking pixels)
Third-party sources (e.g., partners, public databases)

Data Storage and Security: We are committed to ensuring the security and confidentiality of collected data. Measures will be implemented to protect data against unauthorized access, disclosure, alteration, or destruction. Data will be stored in secure databases with restricted access, and appropriate technical and organizational safeguards will be employed to mitigate risks.

Data Usage and Sharing: Collected data will be used solely for the purposes outlined at the time of collection or for other legitimate purposes permitted by law. We may share data with trusted third parties, such as service providers, partners, or regulatory authorities, only when necessary and in compliance with applicable data protection regulations.

Data Retention: We will retain collected data only for as long as necessary to fulfill the purposes for which it was collected or as required by law. Once data is no longer needed, it will be securely disposed of or anonymized to prevent identification.

Individual Rights: Individuals have certain rights regarding their personal data, including the right to access, rectify, restrict processing, and delete their data. Requests to exercise these rights will be promptly addressed in accordance with applicable data protection laws.

Policy Review and Updates: This data collection policy will be reviewed periodically to ensure compliance with relevant laws and best practices. Updates to the policy will be communicated to all relevant stakeholders as necessary.

*By signing below, you acknowledge that you have read and understood the data collection policy of our organization. If you have any questions or concerns regarding the policy, please contact us.
Signature*
Date*

MonthDayYear
Date
Please select a date and time from the options below to attend an in-person intake interview. During this session, a case manager will review your completed application and supporting documents, and work with you to develop your personalized Success Plan. Please allocate up to two hours for your appointment, as it is essential to stay until the intake process is fully completed and the interview is concluded. Once your appointment is scheduled, a member of our team will reach out to confirm the details.

If you need to reschedule or cancel your appointment, please email aisha.jones@palw.org with your preferred new date and time. Appointments are available on Tuesdays, Wednesdays, and Thursdays at 10:00 AM and 2:00 PM.
Appointment
Notes
Should be Empty:

I.M.P.A.C.T. Client Registration

Emergency Contact Information