Food Pantry Distribution Registration

Food Pantry Distribution Registration Form

We are committed to compassionate service of our community. As small town Kingdom servants, we consider it a privilege to serve you. Please answer the following questions. A volunteer will be with you shortly. Need help? We would love to assist you. May God bless you.  
 *****Note: All information gathered is confidential and will be solely used for the purposes of this ministry.

Food Bank of Northeast Arkansas Assistance Network Shared Case Management Software - Oasis Insight RELEASE OF INFORMATION (ROI)







































The Food Bank of Northeast Arkansas Assistance Network, hereinafter referred to as "Oasis Insight", 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. Food Bank of Northeast Arkansas (Administrating Agency) administers Oasis Insight on behalf of participating agencies of the Oasis Insight Assistance Network, including Hoxie First Baptist Church (Participating Agency). I understand that all information gathered about me is personal and private and that I do not have to participate in Oasis Insight. I have had an opportunity to ask questions about Oasis Insight and to review the basic identifying information, which is authorized by this release for the Oasis Insight Assistance Network Participating Agencies to share. I also understand that information about non-confidential services provided to me by Oasis Insight participating agencies may be shared with other Oasis Insight 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 Oasis Insight.







Please supply the first & last name, relationship to applicant, and date of birth of each resident in the household.















I authorize Hoxie First Baptist Church, as a Oasis Insight Participating Agency, to share my basic, identifying and non-confidential service transactions/information with other Oasis Insight 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 Hoxie First Baptist Church (Participating Agency), as a Oasis Insight Participating Agency, to share my dependent's basic, identifying and non-confidential service transactions/information with other Oasis Insight participating agencies.