Hearts of Hope Caregiver Discovery 8-week workshop 4-1-21

Virtual Hearts of HOPE Caregiver Discovery 8 -week Workshop Starts Thursday April 1st from 6:30 - 8 pm.

*Fill one form out per household. You must hit SUBMIT Button for this form to go through*
Being a caregiver can be tough. Challenging behaviors can be difficult. We need knowledge and skills to be resilient. The workshop will equip parents to understand troubling behaviors, how to decrease the behaviors and how to gain self-awareness to remain in control and preserve the wellbeing of the family. Join ASA Now and Open Hearts on this eight - week virtual workshop

This is a unique science based approach teaches parents key skills to help their children with disruptive behaviors that jeopardize success in school, at home and with their overall health and wellbeing.

The workshops equips parents to understand troubling behaviors, how to decrease the behaviors and how to gain self-awareness to remain in control and preserve the wellbeing of the family.
*Deadline to register is Monday 3/22/2021 but registration fills up quickly so reserve your spot now. **You must hit SUBMIT Button for your registration to go through*

Please read this information in its entirety before registering.
This is a FREE event
We need to capture some important information to help coordinate care.

Please take a moment to fill this form out in it's entirety.

An automatic confirmation email will be received*
If you are a Foster or Kinship family, would you like to be considered to receive Free Food and Clothing? *

Yes No
What events are you interested in learning more about? (check all that apply) *

Jacob's Mission Community Center (after school tutoring, dance, music, life skills, sports) Foster Hope Placement Bags filled with essentials Foster Hope Food Box Foster Hope School Backpacks Foster Children's Birthday Party Life Skills Workshops (age 14 and over) Weekly Food Distribution (Trader Joes, Safeway & Midwest Food) Jacob's Law Presentation (behavioral health timelines) Clothing from our Giving Closet Parent's Night Out for Foster, Kinship & Adoptive Families Family Social Get Together for Foster, Kinship & Adoptive Families Christmas Event for Foster, Kinship & Adoptive Families Christmas Gifts for Kinship Families Yearly Couples Retreat Yearly Trauma Mama Retreat
Primary Caregiver's Name #1 *

Last Name First Name
Primary Caregiver's Name #2 *

Last Name First Name
Current Address *

Street Address

City Postal/Zip Code

COUNTY you reside in
Cell Phone Number *

Area Code Phone Number
Emergency Cell Phone Number

Area Code Phone Number
E-mail *
Are you an (check all that apply)

Unlicensed Kinship Caregiver Licensed Kinship Caregiver Licensed Foster Caregiver Tribal Foster Caregiver Caregiver with Guardianship to Child with Child Welfare Involvement Foster/Adoptive Family
Total Number of People Currently Living in the Home? *
Includes all Adults and Children
Total Number of Adults Living in the Home (including children over 18 who are no longer in high school) *
(This includes adult children age 18 and over who are out of high school)
Total Number of Children Living in the Home (including children over 18 who are still in high school) *
(Children under 18 and those over 18 who are still in high school)
Total Number of Children in Foster Care, Tribal Foster Care, or DCS Guardianship Living in the Home (including those 18 and over who are still in high school): *
(This does NOT include non-DCS kinship or guardianship without DCS involvement.)
Number of Adopted Children Living in the Home? *
(Under 18 and those over 18 who are still in high school)
Number of Biological Children Living in the Home? *
(Under 18 and those over 18 who are still in high school)
Number of Non-DCS Kinship or Guardianship Children WITHOUT DCS Involvement Living in the Home? *
(Under 18 and those over 18 who are still in high school)
How many adults will be in attendance? (virtually or in-person) *
Is a certificate of attendance needed? *

Yes No
Continue with Consent *

Yes

Click Here to Consent
Liability Release - I do hereby release ASA Now, Jacobs Mission Community Center, their agents, employees, personal representatives, affiliates, and any and all persons, firms or corporations liable or who might be claimed to be liable, whether or not herein named, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, arising out of or in any way relating to injuries and damages, as a result of being present on Jacobs Mission Community Center. I recognize that there may be inherent risks associated with attending or participating in this event. You have been fully informed of your consent, waiver of liability, and release before entering the event.
I have reviewed, understand, and agree to comply with the above terms *

Agree
By participating in or attending this event, you consent to interview(s), photography, audio recording, video recording and its/their release, publication, exhibition, or reproduction to be used for news, web casts, promotional purposes, telecasts, advertising, inclusion on websites, social media, or any other purpose by ASA Now. Images, photos, and/or videos may be used to promote similar ASA Now events in the future, highlight the event and exhibit the capabilities of ASA Now. You release ASA Now, its officers and employees, and all persons involved from any liability connected with the taking, recording, digitalizing, or publication and use of interviews, photographs, computer images, video and/or sound recordings. By attending this event, you waive all rights you may have to any claims for payment or royalties in connection with any use, exhibition, streaming, web casting, televising, or other publication of these materials, regardless of the purpose or sponsoring of such use, exhibiting, broadcasting, web casting, or other publication irrespective of whether a fee for admission or sponsorship is charged. You also waive any right to inspect or approve any photo, video, or audio recording taken by ASA Now or the person or entity designated to do so by ASA Now. You have been fully informed of your consent, waiver of liability, and release before participating in this event.
I have reviewed, understand, and agree to comply with the above terms *

Agree
Signature *

Clear
Should be Empty:

Virtual Hearts of HOPE Caregiver Discovery 8 -week Workshop Starts Thursday April 1st from 6:30 - 8 pm.