Food Bank of Northeast Arkansas Assistance Network Shared Case Management Software - Oasis Insight RELEASE OF INFORMATION (ROI)

First Name

Last Name

Date of Birth

Physical Address

Mailing Address

City

State

Zip/Postal Code

Country

Phone Number

Email

Gender
Female
Male

What is your present marital status?
Divorced
Married
Single

What is your present level of education completed?
College
High school-incomplete
High school/GED

Are you employed?
Full Time
Part Time
Unemployed
Disabled

Name of Employed

Employer

Monthly Income

List Other Income (Person Employed/Employer/Monthly Income)

What is your present housing situation?
Homeless
Rents a dwelling
Own a dwelling
At risk of being homeless
Other

If other, please explain?

The Food Bank of Northeast Arkansas Assistance Network, hereinafter referred to as "Oasis Insight", is a shared, computerized record keeping system that captures information about people experiencing need for emergency services, including but not limited to assistance with utility bills, medications, rent/mortgage payments, etc. Food Bank of Northeast Arkansas (Administrating Agency) administers Oasis Insight on behalf of participating agencies of the Oasis Insight Assistance Network, including Hoxie First Baptist Church (Participating Agency). I understand that all information gathered about me is personal and private and that I do not have to participate in Oasis Insight. I have had an opportunity to ask questions about Oasis Insight and to review the basic identifying information, which is authorized by this release for the Oasis Insight Assistance Network Participating Agencies to share. I also understand that information about non-confidential services provided to me by Oasis Insight participating agencies may be shared with other Oasis Insight Participating Agencies. This Release of Information will remain 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 Oasis Insight.

Please supply the first & last name, relationship to applicant, and date of birth of each resident in the household.

Resident's First Name

Resident's Last Name

Relationship to Applicant

Date of Birth

Resident's First Name

Resident's Last Name

Relationship to Applicant

Date of Birth

Resident's First Name

Resident's Last Name

Relationship to Applicant

Date of Birth

Resident's First Name

Resident's Last Name

Relationship to Applicant

Date of Birth

Resident's First Name

Resident's Last Name

Relationship to Applicant

Date of Birth

Other Resident's Names & Ages

Would like to receive notifications or updates on the early distribution of perishable foods?
Yes
No

What is you personal contact preference?
Phone
Text
Email
Other

Do you attend our church?
Yes
No
In the process

Would you like to talk to counselor?
Yes
No

Share with us about it...

I authorize Hoxie First Baptist Church, as a Oasis Insight Participating Agency, to share my basic, identifying and non-confidential service transactions/information with other Oasis Insight 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 Hoxie First Baptist Church (Participating Agency), as a Oasis Insight Participating Agency, to share my dependent's basic, identifying and non-confidential service transactions/information with other Oasis Insight participating agencies.

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

Date

Food Pantry Distribution Registration

Food Pantry Distribution Registration Form

Food Bank of Northeast Arkansas Assistance Network Shared Case Management Software - Oasis Insight RELEASE OF INFORMATION (ROI)