Enrich Enrollment -Foundation for Foster Children

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This request is being submitted by(Required)

If other, please specify(Required)

Submitter Email(Required)

Personal Information

Student Name(Required)

First Last

Date of birth(Required)

MM slash DD slash YYYY

Age(Required)

Is student under or over 18?(Required)

Under 18

Over 18

Gender(Required)

Ethnicity(Required)

Grade(Required)

Is the youth a parent?(Required)

Yes

Is the youth employed or in secondary education? (for students 18+)(Required)

Yes

Is the youth incarcerated?(Required)

Yes

Is the youth on track to graduate HS? (if student is in HS)(Required)

Yes

Is the youth pregnant?(Required)

Yes

Is the youth homeless?(Required)

Yes

Is the youth employed?(Required)

Yes

Current living situation(Required)

Foster Home

Group Home

Transitional Home

Other

If other, please specify(Required)

Group Home Name(Required)

Address(Required)

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

Contact Information (Over 18)

Youth Phone Number(Required)

Youth Email(Required)

Emergency Contact(Required)

First Last

Emergency Contact Phone(Required)

Contact Information (Under 18)

Student Phone Number (if Applicable)(Required)

Student Email (If Applicable)(Required)

Caregiver Name(Required)

First Last

Caregiver Phone Number(Required)

Caregiver Email(Required)

Case Manager Information/Child Welfare Team

Case Management Agency/Community Base Agency(Required)

Case Manager Name(Required)

First Last

Case Manager Email(Required)

Case Manager Phone(Required)

Please include the name, phone number and email of any other child welfare team members to be included in collaboration & communication.

Interests and Hobbies

To help us design experiences and support that matches your interests, please select your top interests and hobbies:

What types of activities are you most interested in? (Select all that apply)(Required)

Arts & Crafts

Music & Singing

Dance & Performing Arts

Sports & Athletics

Science & Technology

Reading & Writing

Outdoor Activities (e.g., hiking, camping)

Gaming & Board Games

Community Service & Volunteering

Cooking & Baking

Other

If other, please specify(Required)

Have you participated in any activities like these before?(Required)

Yes

Is there something new you would like to try?(Required)

Celebrations

We love to celebrate important milestones! Please help us learn how we can celebrate with you.

Would you like us to help celebrate your birthday (foster child/youth)?(Required)

Yes

Are there any other special achievements or milestones you'd like us to celebrate (e.g., graduation, sports accomplishments, personal milestones)?(Required)

Safe Spaces

We want to ensure you have the resources you need. Please indicate if any of the following items would be helpful for you:

What resources would you (foster child/youth) find useful in your home or living space? (Select all that apply)(Required)

Hygiene Products

Baby Products

Clothing

School Supplies

Activity Kits (e.g., movie night, game night)

Other

If other, please specify(Required)

Is there anything else you (foster child/youth) would like to share with us about your interests, needs, or things you'd like to experience in the Enrich program?(Required)

Consent to Services

Consent(Required)

I agree to participate in the Enrich program and understand that my information will be used to help tailor activities and resources to my needs. I consent to being contacted regarding Enrich program activities and events. I understand that my photos and stories may be shared with the program for celebration purposes.

Signature(Required)

Media and Photo Release

This 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. Any person who attends Foundation for Foster Children (FFC) events grants permission to the FFC to record his or her visual/audio images, including but not limited to photographs, digital images, voices, sound or video recordings, audio clips, or accompanying written descriptions, and, without notifying such person, to use his or her name and such images for any purpose, including advertisements for future programs and events.

Photo and Testimony Consent(Required)

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.(Required)

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.

Rights and Reponsibilities

Rights(Required)

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.

Responsibilities(Required)

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.

Consent(Required)

I understand and accept the terms of FFC's Rights and Responsibilities agreement

Waiver and Release of Liability Form

In return for being allowed to participate in the Foundation for Foster Children activities and all related activities, including any activities incidental to such participation (“Volunteer Activities”), the undersigned Student or Parent/Legal Guardian of Student if Student is under age 18 (hereafter referred to using “I”, “me”, or “my”) releases and agrees not to sue the Foundation for Foster Children or its officers, directors, employees, sub-contractors, sponsors, agents and affiliates (“the Foundation”) from all present and future claims that may be made by me, my family, estate, heirs, or assigns for property damage, personal injury, or wrongful death arising as a result of my participation in the FFC Activities wherever, whenever, or however the same may occur.

I understand and agree that the Foundation is not responsible for any injury or property damage arising out of the FFC Activities, even if caused by their ordinary negligence or otherwise.

I understand that participation in the FFC Activities involves certain risks, including, but not limited to, serious injury and death. I am voluntarily participating in the FFC Activities with knowledge of the danger involved and I agree to accept all risks of participation. I also agree to indemnify and hold harmless the Foundation for all claims arising out of my participation in the FFC Activities.

I understand that this document is intended to be as broad and inclusive as permitted by the laws of the state in which the FFC Activities take place and agree that if any portion of this Agreement is invalid, the remainder will continue in full legal force and effect. I also acknowledge that the Foundation have not arranged and do not carry any insurance of any kind for my benefit or that of Student (if Student is under 18), my parents, guardians, trustees, heirs, executors, administrators, successors and assigns. I represent that, to my knowledge, I am in good health and suffer no physical impairment that would or should prevent my participation in FFC Activities.

I also understand that this document is a contract which grants certain rights to and eliminates the liability of the Foundation.

Is the student over OR under 18 years old?(Required)

Under 18

Over 18

Student Over 18(Required)

I have read this form and understand that by signing this form, I am giving up legal rights and remedies. I agree to the privacy policy. I am of legal age and am freely signing this agreement.

Parent/Legal Guardian Providing Consent(Required)

First Last

Parent/Legal Guardian Providing Consent(Required)

I am the parent or legal guardian of the Volunteer. I am of legal age and am freely signing this agreement. I have read this form and understand that by signing this form, I am giving up legal rights and remedies.

Electronic Signature - Waiver and Release of Liability(Required)

Conduct at Events and Responsibilities Agreement

When participating in FFC-sponsored events and ticketed activities, all children, youth, and families are expected to adhere to the highest standards of conduct and respect for others. FFC is committed to providing a positive and safe environment for all participants. Please note that any violation of event rules, disruptive behavior, or illegal activities may result in the revocation of eligibility for future Enrichment Services. Additionally, FFC is not responsible for any incidents or consequences that arise due to misconduct or violations of the law during these events. Participants and their families are fully responsible for their actions while representing FFC.

Conduct at Events and Reponsibilities Agreement(Required)

By checking this box, you accept the conduct at events and responsibilities agreement.

ENRICH ENROLLMENT

Enrich Enrollment Form

Personal Information

Contact Information (Over 18)

Contact Information (Under 18)

Case Manager Information/Child Welfare Team

Interests and Hobbies

Celebrations

Safe Spaces

Consent to Services

Media and Photo Release

Rights and Reponsibilities

Waiver and Release of Liability Form

Conduct at Events and Responsibilities Agreement