Good Neighbors of Blount County
Release of Information (ROI)
ADDITIONAL HOUSEHOLD MEMBERS SHOULD BE RECORDED ON NEIGHBOR INFORMATION FORM AND ARE PROVIDING THE SAME RELEASE OF INFORMATION
Good Neighbors of Blount County is a non-profit organization dedicated to providing emergency services, including but not limited to assistance with utility bills, medications, rent payments, etc. This organization asks personal and private information in order to provide coaching and limited financial assistance. It is
shared with utility companies, landlords, etc. directly related to the assistance requested.
I understand that all information gathered about myself and my household by Good Neighbors of Blount County may be shared with other agencies on my behalf should a referral be needed. This Release of Information will remain in effect for 3 years from the date signed unless I make a formal request to the organization that I no longer wish to receive assistance or referrals from Good Neighbors of Blount County.
GOOD NEIGHBORS OF BLOUNT COUNTY FOLLOWS UP WITH EVERY NEIGHBOR WHO RECEIVED COACHING AND/OR LIMITED FINANCIAL ASSISTANCE.