Lehigh Valley Outreach Depot Founded by Wesley United Methodist Church

REFERRAL & LIABILITY WAIVER

Date: 5/24/2018

I, Yahaira Velazquez Cordero, by signing below, absolve the Lehigh Valley Outreach Depot (aka LVOD), my referring agency and my caseworker of any and all liability incurred during the movement, transportation, and use of all items received from the LVOD for my personal use and for use by members of my household.  LVOD assumes no liability for loading items by volunteers or clients.

I understand that all items are provided in "as is" condition and there are no guarantees included. I promise never to sell anything received from the LVOD. If I no longer need or want any item, I will give it to someone in need or return it to the LVOD.

Client's Address: 442 Grant St Allentown, Pennsylvania 18102 Phone: (787) 201-0014

Client's Signature ____________________________

Number of Adults living in home:0

  Age(s) of Children: 

Referring Agency: hispanic center of lehigh valley Caseworker: Fernanda Ferolie

Phone: (610) 868-7800 Email Address: fferolie@hclv.org

I certify that my client, whose signature appears above, has a valid need for assistance from the Lehigh Valley Outreach Depot.

Caseworker's Signature ______________________________

Confirmed Appointment: Saturday, June 23, 2018 @11 AM

This must be signed by the client in the presence of the caseworker. The caseworker is to sign this form in the presence of the client, affirming that the client has a verified need for help.

This form is brought to the LVOD by the client at the date and time indicated above. The client is to bring a photo ID showing the address listed above or, if a different address, a copy of a signed lease showing that the client lives at that address.

NOTE: If the client is unable to keep the appointment, FOR ANY REASON, either the client or the caseworker must contact the LVOD at 610-351-1616 to ask for a future appointment. The call must be received prior to the appointment time so others can be offered an opportunity to use the appointment. Reschedule requests received after the appointed date and time will be refused. Only one reschedule request, if received before the appointment, will be allowed.