CONFIDENTIAL INFORMATION RELEASE 

REQUIRED TO BE COMPLETED

 

I, {name} 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_____________________________________________________

 _______________________________________________________

 _____________________________________________________

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

 

Staff Signature___________________________________________________

 

Date_____________________________

 

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: __________________________