CR Enrollment Packet Authorization and Release of Information and WaiverName(Required) First Last Name(Required) First Last Date of Birth(Required) Month Day Year Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Consent(Required)I hereby give permission for Lift Up Sarpy County and the Sarpy County Community Response partners to share any of my financial, educational, health, and family information which may be necessary to coordinate, refer, approve, or receive community services or assistance from individual, group, or government providers. I understand that information is routinely shared between participants in Community Response, and I agree to hold Lift Up Sarpy County and affiliated entities harmless as a result of their good faith attempt to provide and coordinate assistance. I understand that I have the right to inspect the disclosed information and information being exchanged. I also understand that I may revoke this authorization at any time, except to the extent that action has already been taken, by giving written notice to Lift Up Sarpy County. This authorization is valid for one year. Expiration of this authorization will have no effect upon information already released and Lift Up Sarpy County shall have no obligation to cancel, revoke, delete or otherwise alter access to information already released. I agree to the following:Signature(Required)I hereby agree to the terms set forth above. Full Name Date Witness(Required) Full Name Date Housing Stabilization Prioritization ToolThis form/section will help agencies determine which funding source will best assist the family with their current needs in order to secure safe housing for the next 30 days.Please list all people who currently reside in the household:(Required)Please list one per line and include their full name, age, date of birth and school attending.Zip code(Required)Please enter a number from 00001 to 99999.Phone(Required)Is there an active case with Nebraska Health and Human Services (CPS)?(Required)YesNoDo you currently have a housing voucher?(Required)YesNoIf you do have a housing voucher, from which agency?(Required)Douglas CountyOmaha HousingBellevue HousingHave you received any assistance from any agency in the past 12 months?(Required)YesNoIf yes, from which agencies?Please list any agencies.IncomeEmployment status(Required)How often are you working? Where are you working?(Required)Name of employer What is your net pay?(Required)By hour, week or monthly. Do you pay or receive child support?(Required)YesNoPhoneThis field is for validation purposes and should be left unchanged.
