Protect Yourself: Identity Theft, Elder Abuse & Scams
December 6, 2022 5:30 pm
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Email *
HRCAP
Name *
Address *
Head of Household *
Date of Birth (mm/dd/yy) *
Disability (Disabled) Status: *
Housing Status: *
How long have you been at your current address? *
Phone Number (w/area code) *
Email Address *
Gender Status *
Military Status *
Citizenship Status *
Ethnicity: *
Race *
Multi-Racial Status (please describe):
What is your Primary Language? *
Marital Status: *
Highest Level of Education Completed: *
Student Status *
Number of people in your household (including yourself) *
Your Gross Annual household income from all income sources: *
Required
Income Source: *
Required
Occupation Status: *
Required
Participant Disclosure
I understand that workshop participants will receive professional educational presentations from experts in their appropriate fields. I understand that I am under no obligation to use these professionals/businesses as the sole source for services/business. I understand that participants are free to contact other industry experts/businesses to provide additional information.
HRCAP does not give legal advice. If HRCAP refers me to another agency or organization, I have the right to independently determine whether that agency or organization can address my concerns. HRCAP is not responsible for the services provided to me by others. HRCAP will conduct business that does not interfere with an individual’s right to select his/her own representation for business purposes. HRCAP does not charge any fees for group education.
I understand that representatives or monitors from partner agencies such as VHDA (Virginia Housing) and HUD (the Department of Housing & Urban Development) and others may review participant information for program monitoring and auditing purposes on an annual basis. I give permission for program administrators/funders and/or their agents to hold this information between now and three years for the purpose of program evaluation. I understand and give permission for HRCAP to submit client-level information in the appropriate client management system for funding and monitoring purposes.
BY TYPING YOUR NAME  BELOW, I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE ALL OF THE ABOVE INFORMATION IS ACCURATE *
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