ERUC Clarity Consent

ERUC YHW Clarity Consent

First Name *

Last Name *

Date of Birth *

If you permit it, this agency may share limited information about you with other Your Way Home Montgomery County (YWH) agencies from who you may also seek services. *

I have read and understand

Please check (√) a box: *

This agency may share my personally-identifying information within YWH Data Systems

This agency may not share my personally-identifying information within YWH Data Systems

Please treat information about my children age 17 or younger the same as mine.

Child's First Name

Child's Last Name

Add Remove

When you sign this form, it shows that you understand the following: • We will not deny you help if you do not want us to share your personally-identifying information. • Persons with access to YWH Data Systems are trained in security protocols to protect your data and are only permitted to view your data when you are specifically working with their agency. • If you request services from another YWH agency, your information will be shared for referral purposes only. • YWH may use information derived from your data to create reports to share with funders, the community, and partners to better understand the scope of homelessness and the services being provided. Your personally-identifying information will never be used on these reports.

I have read and understand

Signature

Clear

reCAPTCHA

File Upload

Maximum upload size: 516MB

ERUC Clarity Consent

News and Events