AMI KIDS Orlando "*" indicates required fields Submitter InformationDate* MM slash DD slash YYYY Submitter Name* First Last Submitter Email* Relation to the Youth* Self (Youth over 18) Caregiver IL Specialist/TSS Case Manager/Caregiver Support GAL Other If other, please specify* Youth InformationYouth Name* First Last Youth Email* Youth Phone Number* Date of Birth* MM slash DD slash YYYY Age* Is the youth a parent?*YesNoGender* Female Male Ethnicity* African-American Asian-American Caucasian Hispanic-Latino Multi-Ethnic Other Placement Type* Foster Home Relative Non-Relative Group Home In-Home Court Ordered/Voluntary/Diversion Age 18+ Other Group Home Name* Housing Type* Renting Student Housing Living with a friend/family member Transitional housing Other Address where youth resides:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County of Residence* Orange Osceola Seminole Grade*6789101112GEDCollege/TradeNot Enrolled in School/CollegeSchool Currently Attending* School Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is the youth employed or in secondary education? (for students 18+)*YesNoN/AIs the youth incarcerated?*YesNoIs the youth on track to graduate HS? (if student is in HS)*YesNoIs the youth pregnant?*YesNoIs the youth homeless?*YesNoRisks - Please select all past/present risk factors:* Running away Skipping school Homeless/lack of stable housing Unemployed/employment barriers Transportation barriers Teen parent Juvenile justice involvement Mental health diagnosis Academic concerns/barriers Substance abuse Risky sexual behaviors Lack of familial/peer support Relationship violence Physical health/medical concerns Other If other, please specify*Needs - Please select all areas you hope to have your Advocate assist with:* Housing Transportation Employment Education Mental/Physical Health Parenting Financial Literacy Life skills development Other If other, please specifyChild Welfare TeamIs the youth's case managed by a state/case management agency or community organization?* Child Welfare Agency/Case Management Community Organization N/A Case ManagerCase Management Agency* CHS GCJFS OHU Other Case Manager Name* First Last Child Welfare Team: Primary Contact Phone Number*Child Welfare Team: Primary Contact Email* County Case Managed Out of:* Orange Seminole Osceola Other Please include the name, phone number and email of any other child welfare team members to be included in collaboration & communication.Community OrganizationPlease specify the community organization's name* Contact Name* First Last Contact Phone Number*Contact Email* Primary Support - Caregiver InformationPrimary Support Name* First Last Primary Support Number*Primary Support Email* Release of InformationBy signing below, I approve the release of the confidential information provided in this referral to FFC, its contracted tutoring agencies and its funding agencies, including but not limited to, Orange County Commission for Children and Embrace Families.Electronic Signature: Release of Information* Please type first and last nameElectronic Signature: Release of Information By checking this box you accept this electronic signature. Consent to ServicesThe Foundation for Foster Children has partnered with AMIKIDS Orlando to offer bi-weekly life skills workshops to any student who resides and gets services through AMIKIDS. Foundation services include supportive services, life skills development, and training. This includes identifying needs and linking AMIKIDS to internal programs and community resources. FFC provides advocacy, planning, and coaching to ensure each youth receives personalized support to achieve success. Youths 18 and older must provide explicit consent before services will be initiated. Consent must be provided by the caregiver, caregiver support, IL specialist, TSS, GAL, AMI staff or their respective supervisors before services will be undertaken for youth 14-17.I agree to attend bi-weekly life skills workshops and actively participate in all aspects of program delivery*YesI agree the youth will meet attend bi-weekly life skills workshops and actively participate in all aspects of program delivery*YesConsent to Services Statement* By signing below, I hereby give the Foundation for Foster Children (FFC) consent to provide services to the youth named herein. I understand this includes bi-weekly life skills workshops and other services. I agree to share notes and records, in addition to provide consent to FFC and their staff to share information, as necessary, to maximize collaboration and communication. Consent to Services Statement* By signing below, I hereby give the Foundation for Foster Children (FFC) consent to provide me (youth named herein) with bi-weekly life skills workshops and other services. I understand this includes Advocate and other FFC staff meetings with myself and my support team including professional such as child welfare team and school personnel. I agree share records and that the Advocate and FFC may share information, as necessary, to maximize service delivery. Electronic Signature: Consent to Services* Please type first and last nameElectronic Signature Consent to Services By checking this box you accept this electronic signature. Media/Photo Consent Form and TestimoniesThis consent and release form grants permission to Foundation for Foster Children for the use of testimonies, photograph(s) or electronic media images. Images will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time archived. Media/Photo/Testimonies consent forms and release will expire may 1st of 2024, unless: *Child turns 18, new consent form will be required *Change in placement for children under 18, new consent form will be required with current legal guardian signature. *Legal guardian/child/young adult choices to withdraw their consent for any reasons.Photo and Testimony Consent* I do give consent I do not have permission to provide consent Please provide the name, phone and email address of the individual with permission to provide/deny photo consent.* Media/Photo Consent Form and Testimonies* By signing below, I hereby give the Foundation for Foster Children (FFC) permission to use my photograph and use an approved story in FFC marketing materials including, but not limited to, the website and print materials of FFC. I understand that I will not receive compensation for the use of this likeness in any form. Electronic Signature: Photo/Testimony Release* Electronic Signature: Photo/Testimony Release By checking this box you accept this electronic signature. Rights and ResponsibilitiesRights* 1. Freedom from discrimination: You have the right to freedom from discrimination related to age, ethnicity, national origin, gender, disability, religion, sexual orientation, gender orientation, values and beliefs, marital status, etc. 2. Identity and provider credentials: You have the right to know the identities, titles, specialties and affiliations of all staff and volunteers of FFC and its contracted tutoring providers, as well as anyone else involved in your service. 3. Rules, regulations and policies and procedures: You have the right to know about FFC’s rules, regulations and policies and procedures that are pertinent to the mission or type of service which you receive. 4. Service plan: You have the right to be aware of the decisions about your service. You have the right to select when you would like to receive services and to decide when to stop services. You have the right to change your service plan at any time. You have the right to refuse to participate in any service. You may change your mind and return to services after refusing service without affecting ongoing or other FFC services you may be involved in. 5. Confidentiality: You have the right to confidentiality of all information given to or obtained per rules and regulations of the US Department of Health and Human Services, Health Resources and Services Administration, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), US Department of Justice Civil Rights Division, JTFPI, and other local, county, state and federal laws, directives, and/or guidelines. 6. Client grievance procedures: You have the right to voice complaints at any time. You have the right to receive a response and resolution to any grievance, complaint or suggestion in writing in a timely manner according to FFC’s Client Grievance Policies and Procedures. Select AllResponsibilities* 1. Correct and complete information: You have the responsibility to provide correct and complete information to FFC about your youth’s demographics, case status, academic records, and all other information required during the client intake process. You have the responsibility to provide immediate notification of any changes to placement or case status. 2. Service plan adherence: You have the responsibility of following the agreed upon service plan. And must give adequate notice if there will be a change to the plan. 3. Voicing complaints, problems, and/or suggestions: You have the responsibility for voicing complaints, problems, and/or issues in an appropriate and timely manner via FFC’s grievance process. Select AllConsent* I understand and accept the terms of FFC's Rights and Responsibilities agrementSignature*Electronic Signature By checking this bow, I agree to this as my electronic signature.
