In order to receive federal funding we must ask demographic information including your racial and ethnicity identity for statistical reporting. Please indicate below the total number of persons for each demographic category.
To receive assistance you must have a valid picture ID for the head of the household, and the following proof of current monthly income or no income for EVERYONE in the home 21 years of age and over. Check all that apply.
Please note there are varying residency restrictions for differing programs.
All proofs on file are valid only for the current fiscal year (July 1st-June 30th) before renewal is necessary. Please report any changes to household size or income within a current fiscal year at the time of the next visit. Failure to report changes may be grounds for denial of service. Please note that the listed household for this application will be consistent for all programs at Portage Community Center, including hosted, partnered and independent programming. Discrepancies may be reported to necessary agencies. Thank you.
AUTHORIZATION TO RECEIVE AND RELEASE CLIENT INFORMATION AND DECLARATION STATEMENT
I hereby give authorization to the Portage Community Center (PCC), its staff, student interns and volunteers to verify the information provided with any organization or agency I am currently working with in order to resolve my emergency. In addition, I authorize the release of information about my case to partnering agencies and organizations that may wish to verify information about my case in order to make appropriate service referrals and to coordinate service planning.
This consent to receive and release information will remain active for the remainder of the current fiscal year (July 1st – June 30th) unless I revoke this release in writing. I understand that revoking my consent may affect my ability to receive services from the Portage Community Center and other partnering agencies.
I certify that all information I have provided is current and true. I understand that falsifying any information is grounds for termination of my relationship with the Portage Community Center.