Language
  • English (US)
  • Español
  • Italiano
  • CAGC
  • CLIENT INTAKE FORM

    Community Action of Greene County, Inc.
  •  -


  • TYPE OF INCOME
  • TYPE OF INCOME

    Enter below
  •  
  • SERVICES RECEIVED

    Enter below
  •  
  • APPLICANT INFORMATION
  • HOUSEHOLD MEMBERS

  • 2ND HOUSEHOLD MEMBER
  • 3RD HOUSEHOLD MEMBER
  • 4TH HOUSEHOLD MEMBER
  • 5TH HOUSEHOLD MEMBER
  • 6TH HOUSEHOLD MEMBER
  • You have applied for one of the programs or services that are offered by Community Action of Greene County, Inc.  As part of our commitment to the people in our communities, we want to supply you with all the available services that may pertain to your household.  Based on the information you have given, you will be contacted by programs that may be of assistance to you or your family.

    Florence Ohle, Executive Director

  • REASON FOR VISIT
  • CONFIDENTIAL INFORMATION RELEASE
  • CONFIDENTIAL INFORMATION RELEASE 

    TO BE COMPLETED IN OFFICE WITH STAFF
  • I, ____________________________________________ give permission to the staff of

    Community Action of Greene County, Inc. to exchange information regarding my case

    with any appropriate social service, child protective service, adult protective service,

    medical, mental health or counseling agency, educational, housing, day care,

    employment agency, employer or_________________________________________________________

    ___________________________________________________________.

      

    Signature: ___________________________________________

     

    Witness: ____________________________________________

  • CLIENT CODE OF CONDUCT
  • CLIENT CODE OF CONDUCT

    As a Client I will:

    Treat everyone with respect and courtesy

    Adhere to Community Action policies and guidelines

    Work cooperatively with Community Action staff and volunteers

    Commit no illegal or abusive act

    Not engage in financial transactions with staff or volunteers

    Smoke only in designated area and away from children

    Report any unsafe conditions and accidents to staff as soon as possible

    Sign and abide by the Confidentiality Statement

    Refrain from the possession of all weapons

    Community Action will:

    Provide a safe environment

    Refer clients to other professionals when appropriate

    Provide training, case management, support and assistance

    Treat everyone with respect and courtesy

    Adhere to Community Action policies and guidelines

    Work cooperatively with clients

    Commit no illegal or abusive act

    Not engage in financial transactions with clients

    Smoke only in designated area and away from children

    Sign and abide by the Confidentiality Statement

    Refrain from the possession of all weapons

     

    Client Signature__________________________________________________

     

    Staff Signature___________________________________________________

     

    Date_____________________________

     

  • CAGC
  • EMERGENCY FOOD PANTRY GUIDELINES

     

    An application must be completed, received and/or updated at every visit even if you have recently done so.

     

    The food pantry will be available to eligible households (3) three times during a (6) six-month period.  Referrals to other community food pantries may be made when appropriate or when one has exceeded their visits.

     

    Food Pantry customers will be asked to sign off each time the pantry is utilized.  This record will be kept on file by Community Action of Greene County, Inc. and will be available to the food pantry customer if they are unsure when they last used the pantry or if they have reached the (3) three times in (6) six-months guideline.

     

    Community Action of Greene County, Inc. reserves the right to ask for household composition.

     

    PLEASE SIGN ONCE PER VISIT ONLY

     

    Date: ___________        Signature: __________________________

     

    Date: ___________        Signature: __________________________

     

    Date: ___________        Signature: __________________________

  • CAGC








  • CAGC
  • BUDGET WORKSHEET FOR ENTIRE HOUSEHOLD

  •  
  •  
  •  
  • Should be Empty: