Client Eligibility Form

Receiving services at ECCO begins by completing our Client Eligibility form. Once you’ve submitted the form, an ECCO staff member will follow up within 3 business days using the contact information you provide below. All individuals that receive services at ECCO must complete our client eligibility process annually if living in our service area (or every six months if working in our service area).If supporting documents are not turned in within 30 days of application, the request will be discarded.

Please make sure to fill out all required fields for this application to be submitted successfully.

Questions? Or unable to attach the required documents? Please call (843) 849-9220 to speak with an ECCO representative.

Personal Information

Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Please attach a copy of your current personal photo I.D.

Drop files here or

Max. file size: 50 MB.

(Examples include: Driver's License, Passport, Military ID, Tribal ID, EAC, etc.)

How many adults are in your household?(Required)

Please enter a number from 1 to 99.

How many minors are in your household?(Required)

Please enter a number from 0 to 99.

Please attach your proof of residency (most current electric or water bill, mortgage statement, or rental agreement).

Drop files here or

Max. file size: 50 MB.

If the bills aren't in your name, you will need to complete ECCO's Documentation of Physical Address form (see form at bottom of page):

Do you have insurance (Medicaid, Medicare, or Private)?(Required)

Regardless of status, all applicants must complete ECCO's Declaration of Insurance form (see form at the bottom of page)

What services are you interested in receiving?(Required)

Food

Financial Assistance

Clothing

Dental Services

Medical Services

Prescription Assistance

Asset Development Program

Other

Select all that may apply.

Employment

What is your current source of income?(Required)

Employed

Self-Employed

Social Security Benefits

Unemployment Wages

TANF/SNAP Only

None

Select all that may apply.

Current Employer ?

(if applicable)

Employer City & State Location?

(if applicable)

What is your estimated monthly gross income?(Required)

Please enter a number from 0 to 1000000.

Please attach your proof of income here:

Drop files here or

Max. file size: 50 MB.

Other Info

How did you hear about ECCO?(Required)

Word of Mount

Referral from another organization

211 - Trident United Way

Religious Institution

Social Media

Print Media

Online Search

Other

Select all that may apply.

Release of Information Agreement(Required)

The CharityTracker Assistance Network, “hereinafter referred to as “CharityTracker”, 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. Trident United Way administers CharityTracker on behalf of participating agencies of the CharityTracker Assistance Network, including East Cooper Community Outreach (ECCO). I understand that all information gathered about me is personal and private and that I do not have to participate in CharityTracker. I also understand that if I choose to not participate, this may limit response to my need. I have had an opportunity to ask questions about CharityTracker and to review the basic identifying information. This Release of Information will remain in effect for 3 years from the date noted on this page unless I make a formal request to ECCO that I no longer wish to participate in CharityTracker. I authorize ECCO to share my basic, identifying and non-confidential service transactions/information as needed with other organizations so as to enable the best possibilities for assistance with my need. I authorize the use of a copy of this original to serve as an original for the purposes stated above. I further authorize the exchange of this information with the following agencies and entities as necessary: landlords, utility companies, mortgage companies, St. Vincent de Paul, Operation Home, Family Services, CARES Clinic, ECCO Dental Clinic, ECCO Counseling (as seen necessary), Trident One Stop, WorkKeys, Pro Bono Law, Vocational Rehabilitation and any other agencies in the SafetyNet Network.

Client Services Agreement(Required)

ECCO staff, volunteers, partners and students take pride in providing our services with compassion, collaboration, respect and integrity. We strive to consistently demonstrate these core values. Clients are also asked to demonstrate the same values when interacting with members of the ECCO team. In the unlikely event that a client (or a member of the client’s household) exhibits behavior that is inconsistent with ECCO's values, ECCO has the right to temporarily suspend services for a period of time. By agreeing to this statement, I fully acknowledge that I have read and understand ECCO’s Client Services Agreement. Additionally, I understand that ECCO has the right to confirm and follow up on any and all information that is provided during the eligibility verification process. I also understand that providing false information may disqualify me and my household from receiving services. Lastly, I understand that completing the eligibility process does not guarantee access to any/all services. I am attesting that the information I have provided to ECCO on this date below is accurate and truthful.

ECCO’s Supplemental Forms for Client Eligibility:

(Click on each form below to open and download)

Documentation of Physical Address form
Declaration of Insurance Status form
Self-Declaration of Income form
Statement of Income from Employer
No Income Form

Client Eligibility Form

Personal Information

Employment

Other Info

ECCO’s Supplemental Forms for Client Eligibility:

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