• Application for Social Services

    Application for Social Services

    CAP/Park Scholarship
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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  • VILLAGE OF ARLINGTON HEIGHTS
    SOCIAL SERVICES PROTECTED HEATH INFORMATION
    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    The Village of Arlington Heights ("Village') is required by law to maintain the privacy of certain confidential health care information, known as Protected Health Information or PHI, and to provide you with a notice of our legal duties and privacy practices with respect to your PHI. The Village is also required to abide by the terms of the version of this Notice currently in effect.

     

    Internet, Electronic Mail, and the Richt to Obtain Copy of Paper Notice on Request You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. Please make any such request in writing specifying how or where you wish to be contacted. We will accommodate reasonable requests.
    If you allow us, we will forward you this Notice by electronic mail instead of on paper and you may always request a paper copy of the Notice.


    Revisions to the Notice: The Village reserves the right to change the terms of this Notice at any time, and the changes will be effective immediately and will apply to all protected health information that we maintain. Any material changes to the Notice will be promptly posted in our facilities and posted to our web site, if we maintain one. You can get a copy of the latest version of this Notice by contacting our Privacy Officer.


    Your Legal Rights and Complaints: You also have the right to complain to us, or to the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against in any way for filing a complaint with us or to the government. Should you have any questions, comments or concerns, you may direct all inquiries to our Privacy Officer.

    Privacy Officer Contact Information:
    Privacy Officer, Legal Department, Village of Arlington Heights, 33 South Arlington Heights Road, Arlington Heights, Illinois 60005; (847) 368-5000

    RESIDENT'S COPY

     

     

  • Rights, Responsibilities and Limits of Confidentiality

    Services provided by The Villag of Arlington Heights-Social Services Division are reserved for Arlington Heights residents only. Financial assistance is reserved for residents who are currently experiencing an emergency. This program is intended as a temporary stopgap measure not a long-term solution. Emergency Assistance Funds are not provided by Federal or State entities. Residents may apply once within an 1 year timeframe and funds are provided based on financial need, income, and hardship at time of intake. First time applicants shall be given priority. In-kind donations and Salvation Army funds may be available to residents of unincorporated Arlington Heights.


    The Park and CAP program based on a sliding scale, participants must pay their portion or subsidy will be discontinued. Any scholarships or subsidies awarded will apply to future discounts only and cannot be used for reimbursement of payments already made. Scholarships and subsidies expire one year from date of approval unless otherwise indicated.


    All services are confidential to the extent permitted by law, with the exception of mandated reporting situations, which include but may not be limited to: 1) disclosure of a plan or intent to harm oneself, 2) disclosure of a plan or intent to harm another individual, 3) disclosure or danger of abuse or neglect of children or vulnerable adults, and/or 4) inability to care for one's self.  In these circumstances, there is a duty to act and warn in order to maintain the safety of the resident, other individuals and the community.


    Financial assistance, scholarsbips and subsidies are a privilage, not a right. Applying for assistance, scholarship and/or subsidy does not guarantee assistance will be awarded. All informatiou provided must be accurate and complete. Any refusal to disclose required information, complete required papework and/or lack of compliance with any program requirements will disqualify applicants from receiving assistance. Misuse of assistance will result in revocation of assistance and possible loss of privilege to apply in the fulure.


    For good and valuable consideration herein acknowledged, the undersigned will release, indenmify and hold harmless the Village and its officer, agents, interns,and employees from any and all liability, losses or damages, including attomeys' fees and costs of defense the Village may suffer as a result of claims, demands, suits, actions or proceedings of any kind or nature, in the way resulting from the undersigned's receipt of services, including but not linuted to, any food, clothing or other assistance either monetary or otherwise obtained by the undersigned for his or her own benefit, or any family member, friend, or associate's use. The undersigned will, at his or her own expense, appear, defend and pay all fees of attorneys and all costs and other expenses arising therefrom or incurred in connection there with; and, if any judgments shall be rendered against the Village in any such action, the undersigned will at his or her own expense, satisfy and discharge same. 

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  • Waiver

  • Park District Financial assistance 


    Financial Assistance is available for residents of Arlington Heights only and are determined based on our Sliding Scale Chart.

    1.   IDENTIFICATION FOR EACH MEMBER OF HOUSEHOLD

          •  Driver's license, State ID, or Country ID with Arlington Heights Address.
          •  For children we will accept school forms with their name and Arlington Heights address.

    2.   LEASE OR MORTGAGE STATEMENT

    3.   UTILITY BILL

          •  Gas or electric. No phone bills

    4.   BANK STATEMENT OR CURRENCY EXCHANGE PROFILE FROM THE LAST 30 DAYS

    •  An itemized statement from the last 30 days

    5.   TOTAL HOUSEHOLD INCOME

    •  All that apply: 3 months pay stubs with length of pay period indicated OR current Disability, Social Security or Unemployment award letter OR WZ form OR Tax return (if it is the same as current amount)

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  • APPLICANT INFORMATION
    All questions below are required information for all members of household. Demographic information is required to comply with HUD requirements and is used for research purposes only.

    Please identify BOTH Ethnicity and Race for each applicant

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