Kindness Member Registration Form

Household Composition
Adults in household other than self- provide NAME, AGE, and RELATIONSHIP to you (if none, write N/A):*
Children in Household- provide 1. Full Name 2. DOB 3. Age 4. Gender 5. Relationship to you (if none, write N/A):*
Do people in your household have needs that impact your ability to access or maintain treatment or care?*

YesNo
Do you have a strong functioning support system?

1

2

3

4

5

1 is Not at all, 5 is Very
please explain
Insurance
Please list your primary and secondary insurances (enter N/A if none)*
please explain

Part 3: Financial Information
Do you have a regular source of income?*

YesNo
Do you have difficulty meeting your monthly expenses?*

NoYes
Monthly Income
Employment Incomeblank*
Public assistance  Number*
Social Security Incomeblank*
Disability insurance     blank*
SSI Income   blank*
Alimony     blank*
Child Support   Blank*
Workman's compensation   blank*
Short-term disability   blank*
Survivor benefits     blank*
Rent supplement    Number*
Veteran's assistance    Number*
Pension    Number*
Long-Term Disability    Number*
Unemployment Insurance    Number*
Food Stamps/ EBT  Number*

Total personal monthly income   Number*
Additional monthly income from household members:   Number*
Total monthly household income:   Number*
Annual gross household income:   Number*

Monthly Housing Expenses
Rent   blank*
Total monthly expenses (excluding rent):   Number*

CONSENT FOR ASSISTANCE

I consent and agree voluntarily to receive services from Kindness Initiative (KI) or its Services Provider Partners (SPP). These services may include, but are not limited to or guaranteed to include: providing information on available services; funding or planning resources; providing volunteer advocates to assist in navigating and accessing services and obtaining government benefits; financial aid for rent, emergencies, life cycle events and other select needs; information on food sources; housing; obtaining basic household goods; transportation; employment assistance; home and auto repairs; health and wellness resources such as medical services, dentistry, medications; vision care, auditory services, mental health and physical disabilities resources; “wrap-around,” case management services; legal services; taxation and accounting services; substance abuse and domestic violence counselling; as well as social interaction programs for the elderly and childcare options.
Please read each item below and initial to acknowledge you have read and understood the terms.*

I understand that by submitting an application for funding assistance, personal health care and other information may be exchanged with the Funding, Evaluation, Assistance Committee (FEAC), for services, payments and operational purposes.I understand that I have the right to terminate assistance at any time. I also understand that I have the right to refuse to implement any recommendations.I understand that I am expected to benefit from assistance, but there is no implied or expressed guarantee that I will.I understand that KI is an administrative non-profit organization and responses to Members’ inquiries may be delayed when the office is closed after hours (10AM-4PM), holidays, and weekends. I understand that in the event of an emergency, I will call 911.I understand and request to participate in telecare counseling services provided by both KI and SPPs.
Initials*
IN-PERSON SERVICES

You have requested to receive services from KI and our SPPs, and we are proud to be able to offer these services. In making this request and in signing below, you agree to abide by all KI safety and service protocols. Further, you agree to do the following:
- Abide by the decisions of KI staff and volunteers related to access to the KI and SPP offices;
- Provide truthful and accurate information related to your needs, health and safety questions;
- Stay home if you or a person accompanying you feels ill. Note: You can complete your services discussion via telephone.
By agreeing below, you agree to work constructively with KI and Resource Consultant, and you agree to abide by all stated and/or posted guidelines.*

AgreeDo not agree

Part 4: Authorization to Disclose, Exchange, or Obtain Information
Purpose: The purpose of this disclosure of information is to improve assessment and assistance planning, share information relevant to assistance and when appropriate, coordinate assistance services.
Name*

First NameLast Name
Part 3: Consent for Assistance
I authorize Kindness Initiative (hereinafter "KI") to disclose/exchange all protected health information and records obtained in the course of receiving various types of assistance from KI or its service partners, without limitation, except for the following specific types of information which are not authorized for release (Check all that apply)
No limitations of disclosureAssessmentServices planningDates of servicesGeneral demographicsResource coordinationMental Health RecordsOther
Excluded organizations which are not authorized for release of information (write N/A if none):*
Form of Disclosure: Kindness Initiative reserves the right to disclose information as permitted by this authorization in any manner it deems to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.
RIGHTS

I understand my records are protected under federal regulations and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I can refuse to sign this authorization. I understand that I may inspect or obtain a copy of the information used or disclosed, as provided in 45 Code of Federal Regulations section 164.524. I understand that I have the right to revoke this authorization at any time. I understand that the revocation will not apply to information that has already been released based on this authorization. Any revocation or modification of this authorization must be in writing and received by Kindness Initiative at 9404 Genesee Ave. St. 200 La Jolla, CA 92037.
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
By sending or submitting this form - I acknowledge that the above information is true and correct and that my signature is valid. I also acknowledge that I have the right to revoke this authorization in writing at any time. Any revocation or modification of this authorization must be in writing and received by The Kindness Initiative at 9404 Genesee Ave. St. 200. La Jolla, CA 92037. . I further understand that I will be given a copy of this authorization for my records.

Part 5: Privacy Policy
NOTICE OF PRIVACY PRACTICES SUMMARY NOTICE
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Kindness Initiative (KI) may keep medical information about you. This information is personal and private. We may need to use this information in several ways:
- Conduct, plan and direct your assessment, which may be reviewed at agency meetings.
- Obtain payment from third-party payers.
- Conduct normal operations such as determining appropriate services by KI or Service Provider Partners.
- Under the Health Insurance Portability & Accountability act of 1996 (HIPAA). I have certain rights to privacy regarding my protected health information (PHI). These rights are:
  
  Review the complete notice of privacy practices to signing this agreement.
- Right of access to inspect and copy information in my file.
- Right to amend information in my file.
- Right to an accounting of disclosures made about information in my file.
- Right to request restrictions on how my information is used. I understand KI is not required to agree to my request.
- Right to request the way in which information about me is shared.
- Right to copy of this notice.
- The right to file a complaint regarding privacy with the Secretary of Health and Human Services toll free at 877-696-6775. If I have any questions regarding my privacy rights I can contact KI privacy official at 858.216.1666.
Name*

First NameLast Name
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Image of Front of Driver's License*

Cancelof
Release of Liability:

1. Member and anyone claiming on Member’s behalf releases and forever discharges Kindness initiative and its affiliates, successors, officers, employees, representatives, partners, agents, and anyone claiming through them (collectively, the “Released Parties”), in their individual and/or corporate capacities from any and all claims, liabilities, obligations, promises, agreements, disputes, demands, damages, causes of action of any nature and kind, known or unknown, which Member has or ever had or may in the future have against Kindness Initiative or any of the Released Parties arising out of or relating to any services, advice, assistance, comments, or actions of any Released Party or Parties (“Claims”).

2. This Release shall be binding upon the parties and their respective heirs, administrators, personal representatives, executors, successors, and assigns. Member has the authority to release any Claims and has not assigned or transferred any Claims to any other party. The provisions of this Release are severable. If any provision is held to be invalid or unenforceable, it shall not affect the validity or enforceability of any other provision. This Release constitutes the entire agreement between the parties and supersedes any and all prior oral or written agreements or understandings between the parties concerning actions of the Released Parties. This Release may not be altered, amended, or modified, except by a written document signed by both parties. The terms of this Release shall be governed by and construed in accordance with the laws of the State of California.

3. Both parties represent that they fully understand their right to review all aspects of this Release with attorneys of their choice, that they have had the opportunity to consult with attorneys of their choice, that they have carefully read and fully understand all the provisions of this Release and that they are freely, knowingly, and voluntarily entering into this Release.
I accept the terms and conditions set forth by the Release of Liability above
Should be Empty:

Member Registration Form

Household Composition

Insurance

Part 2: Social and Vocational History

Part 3: Financial Information

Part 4: Authorization to Disclose, Exchange, or Obtain Information

Part 3: Consent for Assistance

Part 5: Privacy Policy