MARC Registration

for registration when attending the Multi Agency Resource Center (MARC) on Saturday, March 23, 2024 at: Centerstone – Steven A. Cohen Military Family Clinic 775 Weatherly Drive Clarksville, TN 37043

Registrant Information

REMEMBER – click the “Consent and Registration – Submit” button at the bottom of the page.

Name(Required)

First Middle Last

Phone Number

Number of Adults (over 17 years old) in Household

Number of Children (under 18 years old) in Household

Military Family Affiliation(Required)

Yes, myself or a member of my family serves or has served

No, myself nor a member of my family has not served

If family member serves/served, please select current status

Active Duty

NG / Reserve

Prior Service Veteran

Authorization for Release of Information Statement(Required)

First Last

By placing my name in the fields above and checking the Consent and Registration – Submit button below – I, the registrant, authorize Tennessee Voluntary Organizations Active in Disaster (TN VOAD) and its member and partner agencies, appropriate Long Term Recovery Groups or Committees and their member organizations, the Federal Government and appropriate agencies of the Federal Government, the State of Tennessee, appropriate agencies of the State of Tennessee and Tennessee State Counties responsible for providing disaster assistance to release information relating to my eligibility for assistance arising from the recent disaster event to those agencies that provide disaster-related assistance. This authorization permits the release of information that is deemed confidential under Federal and State Privacy Acts. This authorization is given to obtain and/or provide assistance I need as a result of this disaster to ensure that benefits are not duplicated. It includes the sharing of information about my application in Tennessee VOAD, the State of Tennessee or a Tennessee County’s possession or under Tennessee VOAD, State of Tennessee, or a Tennessee County’s control. This authorization includes only information necessary to allow the appropriate agency or organizations to determine if I am eligible for assistance from that agency or organization. This information is not to be used for any other purpose. I also understand and acknowledge that signing this does not guarantee that I will get assistance from Voluntary Agencies and/or appropriate Federal, State, or County agencies or representatives. However, without my permission, my information cannot be shared with other agencies or organizations for consideration.