FFC EXPLORE Initiative Registration "*" indicates required fields EXPLORE RegistrationApplication Date* MM slash DD slash YYYY Are you working with an Advocate, or EL Coach or are you receiving tutoring services through the Foundation?*Advocacy StudentEarly Literacy StudentReceiving tutoring services through FFCNo, I'm not receiving any direct services from FFCRegistrationPerson completing the registration*Caregiver filling out for a student under 18(Self) Student over 18Caregiver filling out for themselfCaregiver InformationCaregiver Name* First Last Date of Birth* MM slash DD slash YYYY Gender* Female Male Ethnicity* African-American Asian-American Caucasian Hispanic-Latino Multi-Ethnic Address* 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 Residing County (Family must reside in Orange County to participate)* Orange Student InformationStudent Name* First Last Student Phone Number*Student Email* Who is your advocate?*Carmen MoralesFrank AltomariSarah FalkKeely RickettsAndrew SpeersDaniela SantosValerie AlexisAndy LewallenRebecca JacksonJoseph BurnettAdrianna ButeraQuintyn FlemisterKimberly NassifChristopher OthelotTony McQuayAaron HayesAlivia GonzalezWho is your EL Coach?*Patricia RaginJerel RickettsWhat agency does the youth tutor with?*ETSIn Home TutoringCognitutorYouth InformationYouth Name* First Last Youth Phone Number*Youth Email* Date of Birth* MM slash DD slash YYYY Age* Gender* Female Male Ethnicity* African-American Asian-American Caucasian Hispanic-Latino Multi-Ethnic Placement* Foster Home Group Home Relative (Not Bio Parent) Non-Relative Parent Other Group Home Name* Address where child 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 Residing County (Child must reside in Orange County to participate)* Orange Grade*DaycarePre-KK123456789101112GEDCollegeNot Enrolled in SchoolChild Welfare TeamIs the youth case managed by an state agency/case manager or by a community organization?* Child Welfare Agency/Case Manager Community Organization\ Not Applicable (For Bio/Adopted Children in the home) Case ManagerCase Management Agency* Case Manager Name* First Last Case Manager Phone*Case Manager Email* Case Management County* Community OrganizationPlease specify the community organization name* Contact Name* First Last Phone*Email* Caregiver InformationCaregiver, mentor, family member, etc.Caregiver Name* First Last Caregiver Phone*Caregiver Email* 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 am willing to share my story and/or feedback and I give consent to use my photo. 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. Consent for Release of Information* I approve the release of the confidential information provided in this referral to FFC and its funding agencies, including but not limited to, Orange County Commission for Children. Electronic Signature* First and Last NameElectronic Signature Consent I 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'C Rights and Responsibilities agreement.Signature*Electronic Signature* By checking this box, I agree to this as my electronic signature.
