Heaven-Sent Disaster Information & Release Consent form Heaven Sent Disaster Information & Release Consent Heaven Sent Community Services and Veterans Assistance Disaster Information & Release Consent We need to help… We just HAVE to help! It’s in our souls. Be the LIGHT that helps others see. Section 1 – Survivor Identification Applicant Full Name (person affected by the disaster) Date of Birth Last 4 of SSN (optional) Current Mailing Address Primary Phone Email Address If you have a FEMA Application Number, list it here (optional) Section 2 – Person or Agency You Authorize This section lets you tell us who we may talk to and share information with about your disaster situation and applications. You are not required to authorize anyone, but it may help you if someone you trust is assisting you. Name of person or organization you authorize to speak with us Relationship to you Authorized person / agency phone number Authorized person / agency email (if known) Section 3 – Information We May Share Please check what information you allow Heaven Sent Community Services and Veterans Assistance to discuss or share with the person or agency named above. You may cross out or leave blank anything you do not want shared. My contact information (address, phone numbers, email, best way to reach me). My application details with Heaven Sent (intake notes, disaster needs, services requested). Information about my FEMA, SBA, VA, or other disaster assistance applications, if known. Limited financial information related to disaster assistance (only as needed to coordinate services). Other information I list here: We will not share medical, mental health, or other sensitive records unless you specifically list and authorize them here, or the law requires us to do so. Section 4 – Partner Agencies and Referrals Heaven Sent Community Services and Veterans Assistance works with other community, faith-based, veteran, and disaster relief organizations. Checking the boxes below lets us share your information with trusted partners only for disaster recovery help. Local, regional, state, or national voluntary organizations active in disaster and their partners. Government disaster assistance programs (such as FEMA, state, county, city disaster or housing programs). Veteran, military, and VA-related programs or partners. Other agencies or organizations I list here: Section 5 – How Long This Consent Lasts Unless you choose a different time, this consent will stay in effect for one year from the date you sign it, or until you withdraw it in writing, whichever comes first. Optional: I want this consent to end on (date) Section 6 – Your Rights, Privacy, and Certification You do not have to sign this form. If you do not sign, we will still do our best to help you, but we may not be able to talk with other people or agencies on your behalf.[web:952][web:955] By signing this form, you allow Heaven Sent Community Services and Veterans Assistance to use and share your information only for disaster relief, case management, referrals, and coordination with trusted partners as you have indicated above.[web:952][web:955] You may cancel this consent at any time by telling us in writing. Canceling it will not change any information already shared, but it will stop any new sharing going forward.[web:952][web:955] We are committed to protecting your privacy. Your information is handled in accordance with applicable privacy and confidentiality laws and is only shared as you authorize or as required by law.[web:953][web:956] Applicant Signature (typed name) Date Signed Print This Consent Email to Tim (opens email) Note: The email button will open your email program addressed to our disaster relief contact. You may need to save or print this form to PDF and attach it to your email.
