Please Note: Summer Camp at The HUB is only for children that live in the 74127 community and/or those that attend to Wayman Tisdale Fine Arts Academy.
Other Camp Activities
It is our expectation at the The Common Good that any child who is enrolled in our program attends on a regular basis each week, that is Monday-Thursday. If your child plans to attend another camp or be absent a week, please fill out the days which your child attends so we know when to not expect your child. Your child will not be able to attend Hub on the days in which they are enrolled in other programs unless the Hub is notified in advance.
MEDICAL RELEASE AND AUTHORIZATION FORM
In case of emergency, I hereby give our (my) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any.
Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) hereby assume all transportation costs.
This authorization and permission form is valid for all The Common Good activities for the 2020-2021 school year.
Release Form for Media Recording
I, the undersigned, do hereby consent and agree that The Common Good, its employees, Board members, volunteers, and agents have the right to take photographs, videotape, or digital recordings of me and use these in any and all media, now or hereafter known, and exclusively for the purpose of advertising or promoting The Common Good or any entities with which we partner. I further consent that my name and identity may be revealed therein or by descriptive text or commentary.
I do hereby release to The Common Good, its Board, employees, volunteers, and agents all rights to exhibit this work in print and electronic form publicly or privately and to market and sell copies. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used.
I understand that there will be no financial or other remuneration for recording me, either now or in the future.
I also understand that The Common Good is not responsible for any expense or liability incurred as a result of my participation in this recording.
I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.
For children under 18 years of age, Parent/Guardian Name signature is required:
THE COMMON GOOD
RELEASE OF LIABILITY FORM
In consideration of my child participating in The Common Good’s Learning Center activities. We/I, do for ourselves (myself) and for and on behalf of my/our child-participant do hereby release, forever discharge and agree to hold harmless The Common Good and its employees, Board members, volunteers, and agents thereof from any and all liability, claims, or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and child-participant that occur while said child is participating in the activity sponsored by The Common Good.
Furthermore, We/I and for and on behalf of our/my minor child-participant if under the age of 21 years hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participating in recreation and work activities involved therein.
The undersigned further hereby agree to hold harmless and indemnify The Common Good, its employees, board members, volunteers, and agents, for any liability sustained by The Common Good as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereof.
i HAVE READ THE FOREGOING AND UNDERSTAND THE BEHAVIORAL COVENANT FOR PARTICIPANTS AND WILL ABIDE BY THEM AS WELL AS THE DIRECTIONS OF THE LEADERSHIP OF THE COMMON GOOD’S LEARNING CENTER ACTIVITIES.
This Year we will check each student for symptoms of COVID-19 and do a temperature check during check-in to ensure a safe and healthy experience for students and staff.
We will not allow a child to attend programming if they are showing the signs of COVID-19:
We ask that parents/ legal guardians check their child for the signs of COVID-19 each morning before sending your child to the HUB. If your child shows signs of COVID-19, or if they have been around friends or family who show signs for or have tested positive for Covid-19, please do not send them to the HUB until they have been seen by a physician and have tested negative for COVID-19.
THE COMMON GOOD’S COMMITMENT TO SAFETY
By signing this form, I agree to check my child each morning for the signs of COVID-19 before sending them to HUB programming. I agree to not send them to HUB programming if they are showing signs of COVID-19 or if anyone they have been in contact with has been exposed to COVID-19.
A NEW WAY CENTER, LLP INTAKE ASSESSMENT
I/We have received, read or had it read to me/us, and have had to opportunity to ask questions regarding, a copy of the Agency Code of Ethics to Customers Form. By signing below, I am verifying that I/we understand the Agency Code of Ethics.
I/We have received, read or had it read to me/us, and have had to opportunity to ask questions regarding the agency grievance procedures, and if requested I/We received a copy of the Client Grievance Form. By signing below, I am verifying that I/we understand the grievance procedure.
I/We have received, read, and understand the statement in Section III (Confidentiality and Exceptions to Confidentiality including Data Collection and Research, Notice of Privacy Practices). By signing below, I am verifying that I/we have received and understand the Agency Confidentiality and Exceptions to Confidentiality including Data Collection and Research. By signing below, I am verifying that I/we have received and understand the Agency Notice of Privacy Practices.
I/We have read Section IV (Consent for Treatment), understand all of its contents and sign my/our name(s) freely, voluntarily and without coercion. I/We have read Section V (Consent for Telemedicine), consent to receive services over the videoconferencing and/or camera equipment.
I/We have read section VI (Health Information Exchange). I/We understand ANW, as a member of OrionNet ThinkHealth Information Services, may utilize an electronic network to exchange my protected health information with other providers unless I choose not to participate. I/We understand I/We may change this authorization at any time by writing to ANW. I/We understand I/We cannot restrict information that may have already been shared based on this authorization.
I/We hereby consent and state my preference to have my/our physician, clinician, and other staff at ANW to communicate with me/us by email or standard SMS messaging regarding various aspects of my/our care, which may include, but shall not be limited to, test results, prescriptions, appointment, and billing.
I/We understand that email and standard SMS messaging are not confidential methods of communication and may be insecure. I/We further understand that, because of this, there is a risk that email and standard SMS messaging regarding my/our care might be intercepted and read by a third party.
I/We agree to give 24 hours notice of cancellation if not participating in planned services and understand that if I/We do not show up for planned
services, the treatment plan may be reviewed to determine the appropriateness of continued treatment or, possibly, discharge.
I/We understand that services are provided by ANW regardless of ability to pay. If able, I/We agree to pay when services are rendered and charged.
I/We have been made aware that HIV/STD/AIDS and other communicable disease education, counseling, and testing will be made available to me, my spouse, and significant other(s), if desired. During orientation, I have been made aware of the process by which HIV/STD/AIDS testing and counseling services may obtain.
I/We have received an orientation packet including Synopsis of Client Rights, Agency Code of Ethics, Grievance Procedures, HIPAA information and Exceptions to Confidentiality, Program Rules and Expectations (if applicable), Program Description (if applicable), Emergency Contact Numbers, Individual Rights and Responsibilities (if applicable). An ANW employee explained the orientation materials to me/us and I/we fully understand these materials.
I/We have been provided notice of license disclosure for all Licensed Professional Counselors (59 O.S. § 1916.1) and Licensed Behavioral Practitioners (59 O.S. § 1944) that may be involved in my/our treatment. Oklahoma regulations require that you be informed of your counselors’ professional training, orientation/techniques, fees, and credentials. Some counselors may be working towards licensure as a Professional Counselor or Behavioral Practitioner under the auspices of the Oklahoma State Department of Health. He/She is in the process of accruing 3000 hours of supervised experience, which are required for licensure. Until licensed, he/she has a supervising licensee providing supervision. Your counselor will be happy to discuss with you and/or furnish you with printed materials concerning the licensing process. You may contact (without giving your name), the Professional Counselor Licensing Division provided in the attachments. The Professional Counselor Licensing website is www.health.ok.gov/program/lpc. My counselors have satisfactorily supplied me the information regarding his/her practice, licensure, and professional development.
If the client is under the age of fourteen (14), I/We certify that I/We have legal standing to authorize these professional psychological services; or, that I have legal custody and/or other required legal standing to request and authorize professional psychological services for this child.
OKLAHOMA STANDARD AUTHORIZATION TO USE OR SHARE PROTECTED HEALTH INFORMATION (PHI)
I hereby authorize A New Way Center to release information to the following:
Those listed below in this addendum will be given protected access to educationally relevant information concerning your student. In the event the student transfers schools an updated PHI and addendum will need to be placed on file with that school.
Information to be shared: Educationally relevant information
The information may be disclosed for the following purpose(s) only: To discuss educationally relevant information with school personnel, as listed above, as a result of confidential counseling sessions with the student.
I understand that by voluntarily signing this authorization: