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HAND-UP PROGRAM APPLICATION

Please take a moment to fill out the form.
NOTE: ALL FIELDS MUST BE COMPLETED.

SECTION A - REFERRING AGENCY INFORMATION
SECTION B - CLIENT INFORMATION
Is Client a Military Veteran?
Does Client have Health Care?
Does Client have a Disability?
Does Client recieve TANF?
Does Client have an arrest record?
Has Client been to prison?
I've been feeling optimistic about th future
I've been feeling useful
I've been feeling relaxed
I've been dealing with problems well
I've been thinking clearly
I've been feeling close to other people
I've been able tomake up my mind about things
Employment Barriers

Authorizations and Acknowledgements

 

Client

As a Client of Second Chance Society, Inc., I understand and acknowledge that there is limited funding available for the Second Chance Hand Up Program for which I have applied for assistance. I have been informed that the funding for the Second Chance Program comes from private donations, corporate sponsorship's and both public and private grants. I further understand that certain sponsorship's and grants specifically require the Second Chance Society to track outcomes, or in other words to determine what happens to clients in the period following the award of goods and/or services to the client by the Second Chance Society. In most cases the information gathered by the Second Chance Society is used for statistical purposes.

In the event the Second Chance Society provides me with goods and/or services, I agree to cooperate with their need to track outcomes. For the period of one year following the date of assistance given to me by the Second Chance Society, I agree to keep in contact with the Second Chance Society, and to periodically report to them regarding my employment and living situation. I give my authorization for any agency and/or case worker who works with me as a client to release information to Second Chance Society with regard to my employment and living situation for a period of up to one year from the date of the award of any goods or services to me from the Second Chance Society. I further understand that such outcomes will be provided to Second Chance Society’s Grantors and Funders in compliance with contract obligations.

I understand and agree that the story of my success through the Second Chance Society Hand Up Program may be shared by Second Chance Society with others, printed, published or otherwise disseminated. I understand that any such revelation or publication shall be done in an anonymous manner, without identifying me by name, unless I specifically agree that my name may be used.

Case Manager

 

I am the Case Manager who has referred the above client to Second Chance Society for their assistance. I acknowledge that the client has authorized me and my agency to periodically release information to Second Chance Society regarding the client’s employment and living situation for a period of up to one year from the date of award any goods or services from Second Chance Society to the client.

Your request has been successfully submitted! Note: You will hear from a staff member within 5 business days with respect to scheduling an appointment for your client.

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