Applications normally are processed the middle and end of each month, so your form will be held until the next application date and you will be contacted by a volunteer.
NOTE: Even if you complete your form online, be prepared to provide ID, bill copy and/or landlord forms as requested.
To be considered for assistance, you must read and agree to the following terms and conditions:
The White County Caring and Sharing, Inc. Assistance Network, hereinafter referred to as “CharityTracker,” is a shared, computerized record keeping system that captures information about people experiencing need for emergency services, including but not limited to assistance with utility bills, medications, rent/mortgage payments, etc. White County Caring & Sharing, Inc. (Administrating Agency) administers CharityTracker on behalf of participating agencies of the CharityTracker Assistance Network, including White County Caring and Sharing, Inc.
I understand that all information gathered about me is personal and private and that I do not have to participate in CharityTracker. I also understand that information about non-confidential services provided to me by CharityTracker participating agencies may be shared with other CharityTracker Participating Agencies. This Release of Information will remain in effect for 3 years from the date noted under my signature at the bottom of this page unless I made a formal request to this Organization that I no longer wish to participate in CharityTracker.
I authorize White County Caring & Charing, Inc., as a CharityTracker Participating Agency, to share my basic, identifying and non-confidential service transactions/information with other CharityTracker Participating Agencies. I authorize the use of a copy of this original to serve as an original for the purposes stated about. I further authorize White County Caring & Sharing, Inc. as a CharityTracker Participating Agency, to share my dependents’ basic, identifying and non-confidential service transactions/information with other CharityTracker participating agencies.
Limits of Confidentiality: The contents of a counseling, intake, or assessment session are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without written consent of the client or the client’s legal guardian. The confidentiality of alcohol and drug abuse, patient records are protected by federal laws and regulations. (See 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 CRF Part 2 for Federal regulations.) It is the policy of this program not to release any information about a client without signed release information. Noted exceptions are as follows:
Duty to Warn and Protect: When a client discloses intentions or a plan to harm another person, the intake person is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the intake person is required to notify legal authorities and make reasonable attempts to notify the family of the client, to prevent clear and immediate danger to a person or persons.
Abuse of Children and Vulnerable Adults: If a client states or suggest that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the intake person is required to report this information to the appropriate social service and or legal authorities, as mandated by law.
All information is strictly confidential and cannot be released without your consent or otherwise limited by state or federal regulation, and except to the extent that action has been taken which was based on your consent, you may withdraw this consent at any time.
By typing your name and clicking the “Continue to Application” button below, you are requesting and authorizing White County Caring and Sharing, Inc. of Cleveland, Georgia to obtain and use information for the purpose of determining eligibility for assistance from the following: Employer or former employer, provider of any services that you are requesting assistance with, including landlord, mortgage lender, power or propane company, DFACS or White County School System, Family Connections or any other party that can provide information relating to your eligibility for assistance and to retain this information on CharityTracker.
By typing your name and clicking the “Continue to Application” button below, you grant permission for White County Caring & Sharing, Inc., to discuss the information you provide in this application with other organizations to determine eligibility in obtaining assistance. (Please note, White County Caring & Sharing, Inc. cannot process your application without this consent.)
I understand that typing my name and clicking the “Continue to Application” button below pledges that the information provided on this application is accurate & true.
I understand falsifying information constitutes fraud and no assistance will be given.
I understand that financial assistance from White County Caring & Sharing is a one-time gift and I cannot re-apply for additional assistance for a period of 6 months.