Fillable Backpack for Kids Application 2022

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Backpack for Kids Application 2022

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Backpack for Kids Application 2022
Date of Application: ____________
Backpacks for Kids registration begins June 1, 2022.
Applications will close once 500 applicants are accepted.
Documents required by all households to verify residency and number of children:
-Identification of parent/guardian: valid state ID card or driver's license.
-Proof of Las Vegas/North Las Vegas residency (must be dated within the past 60 days): rental
agreement, utility bill, SNRHA agreement or DWSS confirmation.
-Dependent verification (one of the following that lists the dependent’s name and date of
birth): current rental agreement, SNRHA agreement, DWSS confirmation, medical insurance
card or school registration.
Head of Household Contact Information
1. Parent/Guardian Full Name:
2. Parent/Guardian Date of Birth:
3. Parent/Guardian last four numbers of Social Security number:
4. Parent gender (choose one: male, female, trans female, trans male, gender non-
conforming, unsure)
5. Parent race (choose one: American Indian or Alaskan Native, Asian, Black or African
American, Native Hawaiian or Other Pacific Islander, White, Unsure)
6. Ethnicity (does parent identify as Hispanic/Latino?) State yes or no:
7. Veteran? State yes or no:
8. Best phone number to reach parent/guardian:
9. Address:
10. Email address (will be used for communication, please provide an email address that
you check regularly):
11. Please list any other adults in the household (full name and date of birth):
Please list the children in grades K-12 that you would like to register:
Child #1 Full Name:
Date of Birth:
Gender:
Last four numbers of Social Security number:
Race:
Ethnicity (is child identified as Hispanic/Latino?) State yes or no:
Grade:
Favorite Colors/Characters:
Relationship to Head of Household:
Child #2 Full Name:
Date of Birth:
Gender:
Last four numbers of Social Security number:
Race:
Ethnicity (is child identified as Hispanic/Latino?) State yes or no:
Grade:
Favorite Colors/Characters:
Relationship to Head of Household:
Child #3 Full Name:
Date of Birth:
Gender:
Last four numbers of Social Security number:
Race:
Ethnicity (is child identified as Hispanic/Latino?) State yes or no:
Grade:
Favorite Colors/Characters:
Relationship to Head of Household:
Child #4 Full Name:
Date of Birth:
Gender:
Last four numbers of Social Security number:
Race:
Ethnicity (is child identified as Hispanic/Latino?) State yes or no:
Grade:
Favorite Colors/Characters:
Relationship to Head of Household:
Child #5 Full Name:
Date of Birth:
Gender:
Last four numbers of Social Security number:
Race:
Ethnicity (is child identified as Hispanic/Latino?) State yes or no:
Grade:
Favorite Colors/Characters:
Relationship to Head of Household:
Child #6 Full Name:
Date of Birth:
Gender:
Last four numbers of Social Security number:
Race:
Ethnicity (is child identified as Hispanic/Latino?) State yes or no:
Grade:
Favorite Colors/Characters:
Relationship to Head of Household:
Once complete, save your application to your computer and email to
LVFamilyServices@usw.salvationarmy.org. Please title the email subject line “Backpacks 2022”.
Please include the required documents stated at the beginning of the application as well as
your Clarity intake packet when you submit your application.
HMIS ENROLLMENT QUESTIONARE
CURRENT LIVING SITUATION
Type of Residence
Length of Stay in Current Living Situation
DISABLING CONDITIONS AND BARRIERS (PLEASE ANSWER FOR YOURSELF AND YOUR
CHILDREN)
Disabling Condition
Physical Disability
Developmental Disability
Chronic Health Condition
HIV – AIDS
Mental Health Disorder
Substance Use Disorder
Domestic Violence Victim/Survivor
MONTHLY INCOME AND SOURCES
Income from Any Source
NON-CASH BENEFITS (PLEASE ANSWER FOR YOURSELF AND YOUR CHILDREN)
Receiving Non-Cash Benefits
HEALTH INSURANCE (PLEASE ANSWER FOR YOURSELF AND YOUR CHILDREN)
Covered by Health Insurance (PLEASE STATE YOUR COVERAGE)
ADDITIONAL INFORMATION
Sexual Orientation
EDUCATION (PLEASE ANSWER FOR YOURSELF AND YOUR CHILDREN)
Currently Enrolled in School (PLEASE STATE WHAT SCHOOL YOUR CHILDREN WILL BE
ATTENDING)
Highest Level of School Completed (PLEASE ANSWER FOR YOURSELF AND YOUR CHILDREN)
Nevada Community Management Information System (CMIS)
Client Consent for Data Collection and Release of Information
What is the CMIS?
The CMIS is a data system that stores information about homelessness services. Bitfocus, Inc. manages the CMIS for
the CoCs within the state of Nevada. The purpose of the CMIS is to improve services that support people who are
homeless or at risk of homelessness to get housing, and to have better access to those services, while meeting
requirements of funders such as the U.S. Department of Housing and Urban Development (HUD).
What is the purpose of this form?
With this form, you can give permission to have information about you collected and shared with Partner Agencies
that help Nevada provide housing and services. A current list of Partner Agencies is available at
http://nvcmis.bitfocus.com/.
BY SIGNING THIS FORM, I AUTHORIZE the state of Nevada and Bitfocus to share CMIS information with Partner
Agencies. The CMIS information shared will be used to help me get housing and services. It will also be used to help
evaluate the quality of housing and service programs. I understand that the Partner Agencies may change over time.
The information to be collected and shared includes:
● Name, date of birth, gender, race, ethnicity, social security number, phone number, address
● Basic medical, mental health, substance use, and daily living information
● Housing Information
● Use of crisis services, veteran services, hospitals and jail
● Employment, income, insurance and benefits information
● Services provided by Partner Agencies
● Results from assessments
● My photograph or other likeness (if included)
BY SIGNING THIS FORM, I UNDERSTAND THAT:
● Bitfocus and Partner Agencies will keep my CMIS information private using strict privacy policies. I have the right to
review their privacy policies.
● I can receive a copy of this Consent and the Client Information Sheet
● I may refuse to sign this Consent. If I refuse, I will not lose any benefits or services.
● This Consent will expire 5 years from my last CMIS recorded activity.
I may revoke this Consent earlier at any time by returning a completed Revocation of Consent form, available at
http://nvcmis.bitfocus.com/, to nevada@bitfocus.com.
● The revocation will take effect upon receipt, except to the extent others have already acted under this
Consent.
● My CMIS information may be viewed by auditors or funders who review work of the Partner
Agencies, including HUD, The Department of Veteran Affairs, and The Department of Health and Human
Services. I understand that the list of auditors and funders may change over time.
● My CMIS information may be shared to coordinate referral and placement for housing and services.
● My CMIS information may be further shared by the Partner Agencies to other agencies for care
coordination, counseling, food, utility assistance, and other services.
● My CMIS information will be used to help evaluate the quality of social services.
● My CMIS information may be used for research; however, my identity will remain private.
SIGNATURE:
______________________________________ __________________________
Signature of Patient/Client or Representative Date
______________________________________
PRINTED NAME
click to sign
signature
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Refusing Consent and De-Identification of Information
If you refuse consent to have your information shared with Partner Agencies, the following information will be
entered into the system for your profile and will be deemed as anonymous or “de-identified”.
1. Your Social Security Number will be entered as all 0s and the Social Security Number Data Quality field will
be set to Client Refused;
2. Your Date of Birth will be entered as 01/01/[year of birth] and the Date of Birth Data Quality field will be set
to Approximate or Partial DOB Reported;
3. Your First Name will be entered as Anonymous;
4. Your Last Name will be entered as the Unique Identifier automatically assigned by Clarity Human Services;
and
5. The Name Data Quality field will be set to Client Refused.
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Backpack for Kids Application 2022

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Completed 6 July 2022

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