Release Of Information

Required For All Individuals & Families Being Considered

Each family being considered for one of Ellie’s Elves’ Service Programs is required to complete a Release Of Information (ROI) Form. You should receive a confirmation notice after submitting the form, but you will also receive an email with a copy of the information you provided.

Submit completed forms to LetItShineVa@gmail.com (if you print out and complete the PDF Version of the Application or PDF Formulario Imprimible – En Espanol) OR submit your form through the online submission form below.

Please Note: If you wish to retain a copy of this form for your records, make sure to select “send me a copy of my response” at the end of the form – just above the submit button.

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Client's Name (Head of Household) *

First

Last

Email Address *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

MM / DD / YYYY

Phone *

Select the option that best relates to your assistance needs below: (Only Select One) *

Home Fire Recovery
Clothing Assistance
Meals Assistance
Holiday Assistance
Financial Assistance
Other

Please Explain: *

The Rappahannock United Way Assistance Network, hereinafter referred to as "Charity Tracker," is a shared, computerized record keeping system that captures information about people experiencing need for emergency services, including but not limited to assistance with utililty bills, medications, rent/mortgage payments, etc. The Rappahannock United Way (Administrating Agency) administers Charity Tracker on behalf of participating agencies of the Charity Tracker Assistance Network, including Ellie's Elves (Participating Agency).

I understand that all information gathered about me is personal and private and that I do not have to participate in Charity Tracker. I have had an opportunity to ask questions about Charity Tracker and to review the basic identifying information, which is authorized by this release for the Charity Tracker Assistance Network Participating Agencies to share. I also understand that information about non-confidential services provided to me by Charity Tracker participating agencies may be shared with other Charity Tracker Participating Agencies. This Release of Information will remian in effect for 3 years from the date noted under my signature at the bottom of this page unless I make a formal request to this Organization that I no longer wish to participate in Chairty Tracker.

Demographic Information

What is your Ethnicity? *

Hispanic
Non-Hispanic
Other
Prefer not to answer

What is your race? *

Other
Asian
Black/African-American
Native American
Other Pacific Islander
White
Biracial
Multiracial
Prefer not to answer
Native Hawaiian
South Asian

What is your Preferred Language? *

Gender *

Do you have a Disability? *

Yes
No
Prefer not to answer

Please briefly explain your Disability? *

Employment Status *

Full Time
Part Time
Unemployed

Government Benefits *

Receives Medicaid
Receives Medicare
Receives SNAP (Food Stamps)
Receives Social Security
Receives SSDI (Social Security Disability Insurance)
Receives SSI (Supplemental Security Income)
Receives TANF
Receives Veteran Benefits
Receives WIC
None Of The Above

Are you a Veteran? *

Thank you for your service!

Household Member's Name *

Date Of Birth *

MM / DD / YYYY

Relation to the Client *

I authorize Ellie's Elves, as a Charity Tracker Participating Agency, to share my basic, identifying and non-confidential service transactions/information with other Charity Tracker Participating Agencies. I authorize the use of a copy of this original to serve as an original for the purposes stated above. I further authorize Ellie's Elves (Participating Agency), as a Charity Tracker Participating Agency, to share my dependent's basic, identifying and non-confidential service transactions/information with other Charity Tracker Participating Agencies.

Client and/or Parent-Legal Guardian's Authorizing Signature *

Clear Signature

Date *

MM / DD / YYYY

The original of this Release of Information shall be kept on file with the Agency for a minimum of three years from its expiration date.

Ellie's Elves Program and Services Coordination Opt-In

I, hereby authorize Ellie's Elves to coordinate services with other organizations outside of Ellie's Elves as identified in the Charity Tracker Network to further serve the mission of Ellie's Elves. These services may be in conjunction with or separate from the services provided by Ellie's Elves. This does not guarantee a coordination of other services by other organizations.

Name of the Organization

Contact Person (of the Organization)

Phone Number (For the Contact Person)

Client and/or Parent-Legal Guardian's Authorizing Signature For EE Opt-In *

Clear Signature

Date *

MM / DD / YYYY

Ellie's Elves Photo Release Form (Adult)

I hereby grant permission to Ellie's Elves to use photographs and/or video of me and the adult(s) listed above (under Household Member's Name), for any purpose, including but not limited to being used in publications, news, releases, online, and in other communications related to the mission of Ellie's Elves.

Furthermore, I understand that no royalty, fee, or other compensation shall become payable to me or the adults listed above (under Household Member's Name) by reason of use.

Do you give permission to Ellie's Elves to use the photos and/or video of the adult household members listed above. *

Client and/or Parent-Legal Guardian's Authorizing Signature For EE Photo Release (Adult) *

Clear Signature

Date *

MM / DD / YYYY

Ellie's Elves Photo Release Form (Minor Child)

I, the parent or legal guardian of the children listed above (under Household Member's Name) hereby grant permission to Ellie's Elves to use photographs and/or video of of those minor children, for any purpose, including but not limited to being used in publications, news, releases, online, and in other communications related to the mission of Ellie's Elves.

Furthermore, I understand that no royalty, fee, or other compensation shall become payable to me on behalf of the of the children listed above (under Household Member's Name) by reason of use.

Do you give permission to Ellie's Elves to use the photos and/or video of the minor children listed aboce (household member's name)? *

Client and/or Parent-Legal Guardian's Authorizing Signature For EE Photo Release (Minor Child) *

Clear Signature

Date *

MM / DD / YYYY

For more information about Ellie’s Elves and our impact in the community, check out our website at https://ellieselves.org/impact.

Follow Ellie’s Elves on Facebook at https://www.facebook.com/PrincessElliesElves/

Release Of Information