COVID-19 Quarantine Meal Delivery Referral Form:

List any family and contact information you have for them.
List the Church and any contact information you have.

Disclaimer and Signature

The Charity Tracker Assistance Network, hereinafter referred to as “Charity Tracker,” 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. The Joplin Area Ministerial Alliance (Administering Agency) administrators Charity Tracker on behalf of participating agencies of the Charity Tracker Assistance Network, including Watered Gardens.

I understand that all information gathered about me is personal and private and that I do not have to participate in Charity Tracker. I have had an opportunity to ask questions about Charity Tracker and to review the basic identifying information, which is authorized by this release for the Charity Tracker Assistance Network Participating Agencies to share. I also understand that information non-confidential services provided to me by Charity Tracker participating agencies may be shared with other Charity Tracker 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 Charity Tracker.

I authorize Watered Gardens, as a Charity Tracker Participating Agency, to share my basic identifying and non-confidential service transactions/information with other Charity Tracker 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 Watered Gardens to share dependent’s basic identifying and non-confidential information service transactions/information with other Charity Tracker participating agencies. Further, I understand that Watered Gardens is a clearinghouse for resource that is donated and that Watered Gardens is not responsible for and cannot be held liable for any dysfunction in service or material disbursed to me. I authorize Watered Gardens to use my photograph on social media, the newspaper, or websites related to Watered Gardens.

By signing below, I agree to all above.