ALERTRisk TeensProgram Registration FormDemographic InformationPmfatf psowief amm iogosnauioo at donpmfufmy at potticmf Tiit wimm attitu vt uo tfswf fadi pasuidipaout specific needs This form must be ID: 864171
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1 ALERT ( Accessible Lifesaving Educatio
ALERT ( Accessible Lifesaving Education for at - Risk Teens) Program Registration Form Demographic Information Pmfatf psowief amm iogosnauioo at donpmfufmy at potticmf. Tiit wimm attitu vt uo tfswf fadi pasuidipaou’t specific needs. Th is form must be returned prior to participation in the ALERT P rogram (summer & after school) . Information is kept confidential and is required by the funders of this program. Name:__________________________________________________________ ___ _ (Las t) (First) Address:______________________________________________________ ___ __ _ (Street) (City) (State) (Zi p) Home Phone Number:_________________ Cell Phone Number _________________ Email Address __________________ I would like to receive newsletter & Updates Social Security Number:_________________ __ (Required) Disability Type:(Primary)__________ _____ ___ (Secondary)_______________ _ Gender:_____________ Age:______________ DOB:_______________ Heigh t:__________ Weight:__________ Race/Ethnicity:________________ Who does participant live with? _________________________________ ______ _ Participant Liv
2 es in: Family Home Fos
es in: Family Home Foster Home Group Home Are there any custody issues we should be aware of? No Yes If yes, please provide documentation. _____ _____________________________ Current s chool in attendance: ___________ ___________________ Current g rade : ______ Expected date of graduation: _____ Applying for: Summer Program – year _____________ After School Program – year __________ Employment Readiness – year _________ VR Job Training – year _ ____ Summer or Year round Has this Participant participated in a Coal iuioo gos Ioefpfoefou Liwioh Ppuioo’t psohsan in the past? ____ yes ____ no If yes, when? ____________ Are advocacy or transition services needed ? ____ yes ___ Date Received _____ __________ (For office use only) 2751 S Dixie Hwy West Palm Beach FL 33405 Voice: 561 - 966 - 4288 Fax: 561 - 641 - 6619 Coalition for Independent Living Options, Inc. (CILO) - 2 - Pasuidipaou’t Nanf________________ Emergency and Contact Information Mother Father Name: Name: Home Phone: Home Phone: Cell Phone: Cell Phone: Work Phone: Work Phone: Address: Address: Email:
3 Email: List everyone who is perm
Email: List everyone who is permitted to pick up your child. Name Phone Number Contact in Emergency? Yes or No Yes or No Yes or No Yes or No Yes or No In case of Emergency, Notify (other than a parent) Name:___________________ Relationship:_____________________ Daytime Phone:____________ Evening Phone: ___________________ Pasuidipaou’t Doduos:________________________ Pioof:____________ Medications participant is taking: ______________________________________________________________________ ____________________________________________________________ Pr ecautions:____________________________________________________________ ____________________________________________________________ Is the participant subject to seizures? No Yes Type:____________________ Frequency:_______________________ Special Condi tions:_________________________________________________ Allergies to drugs, food, insects:_______________________________________ Special dietary precautions:__________________________________________ How will the participant be transported to and from th e ALERT program? ________________________________________________________________ Pasuidipaou’t Nanf________________ Coalition for Independent Living
4 Options, Inc. (CILO) - 3 -
Options, Inc. (CILO) - 3 - Special Needs and Accommodations Walks independently: Yes No Assistive Devises: Walker Wheelchair Cane Crutches Other:______ ___ Hearing Impaired: Yes No Hearing Aids: Left Ear Right Ear Special Communication Style: Yes No Nonverbal Oral/Lip Reading Sign Language Communication Board Braille Other – explain________________________________________ Vision Impa ired: Yes No Assistive Devises: Glasses Contact lenses White Cane Other Please list self help needs: Eating:___________________________________________________________ Bathroom:______________________________________________________ __ Dressing:_________________________________________________________ Does the participant swim? Yes No With assistance Independently Excellent Swimming Skills Fair Swimming Skills Poor Swimming Skills Participant can swim in water up to: 3 ft . 5 ft. 8 ft. Over 8 ft. Does the participant need one on one supervision for any type of activities? Yes No If Yes, explain _____________________________________
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Please list and expl ain any concerns you have: ______________________________________________________________________ __________________________________________________________ Is there anything that we should watch for that might indicate a behavior problem may occur? ______ ________________________________________________________________ __________________________________________________________ What is the best approach to deescalating a negative behavior? ________________________________________________________________ __ ______________________________________________________________ Pasuidipaou’t Nanf__________________ Coalition for Independent Living Options, Inc. (CILO) - 4 - Consent I _____________________ hereby give my consent for _____________________ to participate in recreational activities, field trips, and swimming. Yes No Parent/ Guardian Signature:______________________________ Date:________ In consideration of _________________________ being permitted to participate in this program, I hereby release, waive and discharge The Coalition for Independent Living Options, Inc., its agents and employees from all and any liability for injuries, loss or damage and any claim or dama
6 ge do to any injuries to person or prope
ge do to any injuries to person or property from this participant while participating in the program. Parent/ Guardian Signature:______________________________ Date:________ I also agree to emergency treatment by a physician or hospital in the event that I cannot be reached. Parent/ Guardian Signature:______________________________ Date:________ I giv e permission for ______________________ to have his/her photo taken. It may be use for public information. Yes No Parent/ Guardian Signature:______________________________ Date:________ Permission is granted for the participant whose name appears above in still or motion pictures using his/her name for educational, promotional or other proper purposes only. Yes No Parent/ Guardian Signature:_______________________________ Date:_______ Is participant eligible for extended school year? Yes No If s o may we release participants name to The Palm Beach County School District? Yes No Parent/ Guardian Signature:_______________________________ Date________ Coalition for Independent Living Options, Inc. (CILO) - 5 - SERVICE DISCLAIMER CILO ensures service delivery for every individual with a disability who voluntarily contacts the agency expressing a need for assistance, so lo
7 ng as that service falls within uif ahf
ng as that service falls within uif ahfody’t nittioo aoe tdopf og psaduidf. _________ I understand that CILO services are only provided during such time that CILO has th e funding to provide such services. The funding sources, staff, and programming may be subject to change at any time. _________ I understand that CILO is a social service agency and its employees are considered mandatory reporters. As such, the staff is m andated by state and federal statutes to report suicidal disclosures; homicidal disclosures; disclosures of child abuse, incompetent person abuse, vulnerable adult abuse, elder abuse; and to report the willful infection of another with a contagious conditi on known to be fatal. CILO reserves the right to terminate services to any consumer under the following conditions: _________ If staff feels threatened or bullied _________ If there is suspicion of drug, alcohol, or prescription drug abuse _________ If consumer demonstrates excessive lack of follow through/follow up with service referrals or service recommendations ( examples include, but are not limited to, a consumer that does not return calls, attend meetings, or demonstrate an active interest in work ing on the goals drafted in the Independent Living Plan). _________ If staff is sexually harassed; defined as unwelcome sexual advances, reques
8 ts for sexual favors, and other verbal
ts for sexual favors, and other verbal or physical harassment of a sexual nature. _________ If consumer demonst rates discrimination of any kind against any other person in the following protected classes: Race, Color, Religion, National Origin, Age, Sex, Pregnancy, LBGTQ, Citizenship, Familial Status, Disability, Veteran Status, and/or Genetic Information (examples include, but are not limited to, negative comments or jokes, discriminatory treatment toward a CILO staff member, consumer, volunteer, visitor, Board member, or other community partner). _________ I understand, in the event, services are terminated for any of the reasons stated above, I have a right to appeal this decision, in writing, to the Executive Director within 10 days of notification of termination of services. Signature: ___________________ _____ ____________________ Date: __________________ Witness: __________ ______ ______________________ _______ Date: __________________ Coalition for Independent Living Options, Inc. (CILO) - 6 - C. FILE ACCESS/RELEASE/CONFIDENTIALITY POLICY INSTRUCTIONS: Please read each entry below and write your initials on the space provided. YOUR INITIALS: 1. ______ _____ My file will be kept locked to limit access and maintain confidentiality. The Executive Director/CEO or ap
9 propriate staff/designee will have acce
propriate staff/designee will have access to my files. I have the right to review my file at any time on a need to know basis. 2. ___________ Volunteers will have access to my file under only three condition: (A.) If access is deemed necessary by the Executive Director/CEO and (B). Only if the volunteer has signed a written statement of ethics/confidentiality as applies to CILO services. (C). On ly if the volunteer has successfully passed a level 2 background check. 3. ___________ I and/or significant other (if authorized by me in writing) has the sihiu uo sfwifw ny sfdose aoe uo diammfohf uif sfdose’t dooufou cy requesting a conference with the Executive Director/CEO or appropriate staff person/designee. 4. ___________ I understand that third party records (information generated by persons other than CILO personnel) will not be photocopied or released unless under court order (except in certai n cases of domestic violence or sexual assault). 5. ___________ I must provide written consent in order for information about me and/or my family to be mutually exchanged between CILO and other parties such as service/health care providers. I will always reserve the right to revoke the agreement by notifying CILO in writing at any time. 6. __________ I understand that my record will be kept for five (5) years foll
10 owing the closure of my case. At the e
owing the closure of my case. At the end of the five (5) years my file will be destroyed. ------------------------------------------------------------------------------------------------------------ Who can we contact in case of an emergency? Name _____________________ Relationship:__________________ Telephone number_______________________ ___ Coalition for Independent Living Options, Inc. (CILO) - 7 - A. CIL RECORDS POLICY PLEASE READ THE FOLLOWING POLICY AND SIGN BELOW: Tif svmft uiau howfso Cfoufst gos Ioefpfoefou Liwioh’t doogiefouiamiuy/sfdoset pomidift tuauf uiau aoy sfpsftfouauiwf og CIL’t gvoeioh tovsdft, aveiuost aoe/os addsfeiuio g bodies may review for bona fide reasons, consumer files. I understand the policy stated above. ______________________________ __________________________ Cootvnfs’t tihoauvsf Print signed name B. CLIENT ASSISTANCE PROGRAM (CAP) INFORMATION : D isability Rights Florida, implements the Client Assistance Program on behalf of the State of Florida. If you have any problems or questions that the Coalition for Independent Living Options, Inc. cannot help you with you may contact the CAP Program for ad vice and assistance. Disability Rights Florida 1 - 800 - 342 - 0823 (voice) 2473 Care Drive, Suite 200
11 1 - 800 - 346 - 4127 (TDD) Talla
1 - 800 - 346 - 4127 (TDD) Tallahassee, Florida 32308 ______________________________ __________________________ Cootvnfs’t tihoauvsf Date Please make sure to write down the CAP address and/or phone number for future reference. Coalition for Independent Living Options, Inc. (CILO) - 8 - MULTI - MEDIA RELEASE I, _________________________________ HEREBY AGREE TO PARTICIPATE IN THF CPBLITIPN FPS INDFPFNDFNT LIVING’S MULTI - MEDIA ENDEAVOR WHICH ENTAILS APPEARANCE OR COOPERATION IN ANY OF THE FOLLOWING: PLEASE CHECK ALL THAT AP PLY: VIDEO TELEVISION NEWSPAPER NEWSLETTER / MAGAZINE WEBSITE SOCIAL MEDIA _________________________________ CONSUMER NAME _________________________________ WITNESS _________________________________ DATE Coalition for Independent Living Options, Inc. (CILO) - 9 - Release of Information I, ____ ______________________ , hereby give my consent to allow the Coalition for Independent Living Options, Inc.(CILO) to release information as specified below to the following individuals and/or agencies. This authority is given voluntarily and it expires o ne year from the date of this document. The following
12 individuals and/or agencies are authori
individuals and/or agencies are authorized to receive information from the Coalition for Independent Living Options, Inc. on my behalf: Palm Beach County Food Bank ___________________________________ ___________________________________ ______________________________________________________________________ ____________________________________________________ This authority for the Coalition for Independent Living Options to release information is limite d to the following information regarding me and my child or family member with the name of: ____________________________________ Information authorized for release: Coordinator of Youth Services to sign my child’s name with the Palm Beach County Food Bank distribution log. ______________________________________________________________________ __________________________________________________________ Consumer/Guardian signature _____________________________________ Print Signed Name _____________________________________ Signature of Witness _____________________________________ Date signed _____________________________________ Revised October, 2010
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(Release) Coalition for Independent Living Options, Inc. (CILO) - 10 - CSR Goals Independent Living Plan Consumers can waive t he right to an Independent Living Plan by signing below: Consumer Signature:___________________________________Date:__________________ Consumer: ________________________________ Begun: _______________________ Funding source: _____________________ _______ Accomplished: _________________ Staff: _____________________________________ Cancel: ______________________ Office: ____________________________________ Target: _______________________ Area of Access: ______________________ Review: __________ ____________ Goal Type: __________________________ Revised: _____________________ Topic Area: _________________________ Continue: _____________________ Report Complete: _______________ ____ Report Due: ___________________ Service Provider Follow - Up: _____________________ Short Term
14 Goal: _________________________________
Goal: _____________________________________________________________ ____________________________________________________________________________ Long Term Goal: ______________________________________________ ________________ ____________________________________________________________________________ Need: Situation: __________________________________ ___________________________________ __________________________________ ______ _____________________________ Method: (File Plan) ____________________________________________________________________________ ____________________________________________________________________________ Consumer Signature:____________________________ _______Date:________________ Staff Signature:________________________________________Date:________________ Disabilities: ____yes ____no Type of Disability: _________________________ ______ ___ Can consumer benefit from CILO services? ____yes ____no E ligibility Determination: ____yes ____no Coalition for Independent Living Options, Inc. (CILO) - 11 - Coalition for Independent Living Options, Inc. (CILO) - 12 - Coalition for Independent Living Options, Inc. (CILO) - 13 - Coalition for Independent Living Options, Inc. (CILO) - 14