REACH Membership Form

MEMBER INFORMATION

NOTE: PLEASE REMEMBER TO CLICK THE SUBMIT BUTTON AT THE BOTTOM OF THIS PAGE

MEMBER'S FIRST NAME *

MEMBER'S LAST NAME *

BIRTHDATE *

MEMBER'S EMAIL *

AGE *

CELL PHONE *

NICKNAME *

HOME PHONE *

HOME ADDRESS *

CITY *

STATE *

ZIP *

Please list any existing health, education or other community health services you currently use that we should be aware of to better coordinate care. If none, enter N/A. *

Please list any special accommodations or needs we should be aware of to better coordinate care for you/your child. If none, enter N/A. *

Do you have siblings that attend REACH? *

No

Yes

If yes, Name(s) & Date(s) of Birth: *

What race/ethnicity do you identify yourself as? (check all that apply)

Your signature on this page gives your consent for you (if you can give consent) or your child to receive services offered by CHSC/REACH AYC. Because REACH staff coordinate care across key areas of youth development, including supporting academic success, consenting for services includes REACH staff having access to your child’s educational records. Your consent for services also means that we have a duty to inform you about our recommendations of care, so that your decision to participate is made with knowledge and is meaningful. In addition to having the right to stop services at any time, you also have the right to refuse any recommendations, psychological interventions or treatment procedures. If it is determined that REACH services are not appropriate, or not of your choosing, we will work with you to find an appropriate referral. In order to ensure on-going high quality services, you and your child will be asked to complete client satisfaction forms to report on your service experience.

REACH prioritizes safety and security for our Members and the community. As a County-operated building, REACH has internal and external cameras and complies with all privacy laws.

I have read the statements above and give my child permission to meet with REACH staff and Care Coordination team. In order to effectively serve my child, I understand that the REACH staff and Care Coordination team will consult with teacher(s) and school staff in confidence as needed. This consent will be effective for one year and I understand that I may cancel it in writing at any time.

Member’s Full Name *

Parent’s/Guardian’s Full Name

Today's Date *

PARENT/GUARDIAN INFORMATION

PLEASE NOTE: Applicants over 18 enter N/A throughout

REACH provides programming in: Recreation, Education, Arts and Creativity, Career Development, and Health and Wellness. Counseling, Library Services, and Medical Clinic with Dental services are on-site free of charge. REACH is open Monday – Friday. Hours are seasonal and REACH is closed on County holidays. Call or check our website.

If Member is under 18, please provide:

If Other Guardian (relationship)

Primary Parent/Guardian Name *

Relationship *

Primary Parent/Guardian Address *

Primary Parent/Guardian City *

Primary Parent/Guardian Cell Phone *

Primary Parent/Guardian State *

Primary Parent/Guardian Work Phone *

Primary Parent/Guardian Zip *

Primary Parent/Guardian Home Phone *

Primary Parent/Guardian Email *

Opt Out Primary

I would NOT like to receive REACH newsletter and community announcements

Secondary Parent/Guardian Name *

Secondary Relationship *

Secondary Parent/Guardian Address *

Secondary Parent/Guardian City *

Secondary Parent/Guardian Cell Phone *

Secondary Parent/Guardian State *

Secondary Parent/Guardian Work Phone *

Secondary Parent/Guardian Zip *

Secondary Parent/Guardian Home Phone *

Secondary Parent/Guardian Email *

Opt Out Secondary

I would NOT like to receive REACH newsletter and community announcements

EMERGENCY CONTACT PERSONS

(For ALL Members including Members over 18. Members over 18 may list individuals other than parents or guardians.)

1-First and Last Name *

1-Relationship *

1-Home Phone *

1-Cell Phone *

2-First and Last Name *

2-Relationship *

2-Home Phone *

2-Cell Phone *

MEMBER ORIENTATION

All Member applicants must attend a REACH Member orientation. All parents or guardians of REACH Member applicants under the age of 18 MUST also attend a parent/guardian orientation. Orientations finalize the membership process. You must reserve your orientation time in person at the REACH front desk.

MEMBER AGE VERIFICATION

For Member applicants, REACH staff may request verification of age. If needed, a current report card, birth certificate, or passport will be accepted as proof.

MEMBER RELEASE AUTHORIZATION

Parents and/or legal guardians must grant permission to allow youth under the age of 18 to leave REACH. Middle school aged Members being picked up must be picked up by 6pm. Middle school aged Members must remain in the building during program hours. There are no in & out privileges. When picking up your child, please phone the front desk if you will be late at (510) 481-4551. Members will be asked to stay and wait for a ride, however, REACH cannot enforce the desire of the parent/guardian if a child leaves the building of their own free will. The staff will attempt to notify parent/ guardian should this occur.

Release *

I agree that my child/ren can leave REACH by walking or public transportation

My child/ren will be picked up by an authorized adult. I understand that the authorized adult may be asked for identification upon entry to REACH for safety and security reasons

REACH LIMITATIONS OF SERVICE

REACH makes every effort to accommodate Members within its capacity and scope of services. REACH accepts youth between the ages of 11-24 in Alameda County, including those who manifest behavioral, academic, emotional or social difficulties or other forms of distress who could benefit from pro-social activities and developmentally appropriate mental and physical wellness supports.

REACH provides supervised structured and unstructured activities, and because youth may come and go with adult permission, youth requiring higher levels of supervision care due to varying developmental or emotional needs are assessed by Health and Wellness staff and/or Fuente Wellness Center staff to ensure that REACH can meet their needs. In certain instances, REACH may determine that a higher level of care is needed than we can provide. Whenever possible, REACH works with youth, their parents/guardians and other service providers to identify appropriate services that best fit the needs of the youth outside of REACH. Member age exceptions may apply and are determined by Alameda County Healthcare Services Agency Management.

WAIVER, RELEASE OF LIABILITY, ASSUMPTION OF RISK AND CONSENT TO USE IMAGE

This form must be completed and signed by all individual Members who will be participating in any program, class, project, or activity at the REACH Ashland Youth Center and their parents or legal guardians, if the Member is under 18 years of age.

1. The above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, hereby forever RELEASE(S) AND DISCHARGE(S) the County of Alameda (“County”), its employees, elected officials and agents, from any and all liabilities, claims, demands or causes of action that the above-named Member and/or his or her parent or legal guardian may hereafter have for any injuries and damages arising out of the participation in any program, class, project, or activity at any premises owned by the County (including the REACH Ashland Youth Center) or under the auspices of REACH Ashland Youth Center, including, but not limited to, losses caused by the passive or active negligence of the County or hidden, latent, or obvious defects in the premises or equipment used.

2. The above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, understand(s) and acknowledge(s) that certain activities at the REACH Ashland Youth Center (or under its auspices) involving physical activity, agility and contact, have inherent dangers that no amount of care, caution, instruction or expertise can eliminate. The above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, do(es) hereby expressly and voluntarily assume any and all risk of death and/or personal injury, which may be sustained while participating in any activities including the risk of passive or active negligence of the County, or latent or hidden or obvious defects in the premises or equipment used.

3. The above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, acknowledge(s) having been given the opportunity (a) to read this entire document, and (b) to have it reviewed by an attorney. The above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, is/are signing this document voluntarily with a full understanding that by signing it the above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, do hereby release the County, its elected officials, its employees and agents from all liability resulting from my participation in any activities at the REACH Ashland Youth Center.

4. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on ALL heirs and assigns of the Member. The above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, agree(s) to assume all responsibility for any property damage or injury to any person caused by me or my child while participating in any program and/or activity at the REACH Ashland Youth Center.

5. The County is not responsible for the loss or theft of any personal property that the Member may bring to REACH Ashland Youth Center. Members are strongly encouraged not to bring anything of value.

6. The above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, understand(s) the importance of using images and sound recordings of REACH Ashland Youth Center’s activities in printed materials, websites, videos, film, and television broadcasts. Therefore, the above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, give(s) permission for REACH Ashland Youth Center and its program affiliates to use photographs, video recordings, and voice recordings of the above-named Member free of charge. This consent includes the storage, retrieval, and reproduction of information or images. Photographs, videos, audio recordings and the tapes, negatives, and digital media from which images and sound recordings are made, shall be the property of REACH Ashland Youth Center, which shall have the right to publish, reproduce, distribute, and make other uses free of all claims on the part of the above named Member and his or her parent or legal guardian, if the Member is under 18 years of age.

Waiver Member's Full Name *

Waiver Parent's/Guardian's Full Name

Waiver Date *

The attached Notice describes how health information about you may be used and disclosed within the Center for Healthy Schools and Communities (CHSC)/REACH Ashland Youth Center’s (REACH) programs and services, and your rights regarding the use of that information. Please review this summary and the full Notice carefully.

Who will follow the rules in this notice: All CHSC/REACH and contract provider employees, assigned to CHSC/ REACH must follow these rules.

You have a right to:

Ask to see, read and/or obtain a copy of your health record (charges may be necessary).
Ask to correct information that you believe is wrong in your health record.
Ask that your health information not be shared with certain individuals.
Ask that your health information not be used for certain purposes.

Ask to send copies of your health record to whomever you wish (charges may be necessary).
Be informed about who has read your record (for reasons other than treatment, payment and program improvement purposes).
Specify where and how employees may contact you.
Receive a paper copy of the full Notice of Privacy Practices.

CHSC/REACH may use and disclose your health information to improve treatment.

To improve the quality of care you receive, health information may be shared by providers within CHSC/REACH and its contract providers- including health information regarding mental health, substance abuse, HIV/AIDS, sexually transmitted diseases (STD), and developmental disabilities.
There are circumstances when health information about you will not be shared unless you first give your permission for it to be shared.

See “Notice of Privacy Practices” for more information. If you have concerns about how your health information might be (or has been) shared, please speak with your provider.

If you believe your privacy rights have NOT been maintained while receiving CHSC/REACH services, you may file a complaint with CHSC/REACH or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint, send the complaint to the Privacy Officer. You will not be penalized in any way for filing a complaint.

I acknowledge receipt of Center for Healthy Schools and Communities/REACH Ashland Youth Center’s “Notice of Privacy Practices.” I understand that my signature does not authorize disclosure, but only acknowledges that I have received a copy of the full Notice.

Name *

Date *

Relation (if other than youth) *

Youth Name *

Interpreter Name *