Kindness Member Registration Form

Employment Status:*

Full timePart timeUnemployedRetiredUnable to work
Current employer (write N/A if not applicable):*

CONSENT FOR ASSISTANCE

I consent and agree voluntarily to receive services from Kindness Initiative (KI) or its Services Provider Partners (SPP). These services/service referrals 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 and request to participate in case management services provided by both KI and SPPs.I understand that completing this application, initiating services, or receiving a referral from KI does not guarantee membership or continuation of membership.I understand that maintaining membership with KI is contingent on adherence to rules and policies, as well as treating staff and others with respect and courtesy.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, holidays, and weekends. I understand that in the event of an emergency, I will call 911.
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 5: Privacy Policy
When you join our Kindness Initiative as a member receiving services, we collect your name, contact information, and details about your specific service needs and circumstances. All information you share with us is kept strictly confidential and is only used to provide you with appropriate support services. We understand that your privacy is essential to building trust and ensuring you feel safe accessing the help you need.

We never share your personal information or the fact that you're receiving services with anyone outside our organization, except when referring to SPP's that you have consented to, or when required by law or if there's an immediate safety concern. Our staff and service providers are bound by confidentiality agreements and are trained to protect your privacy. All records are stored securely and accessed only by authorized personnel who need the information to provide your services.

You can also withdraw from services without penalty. If you have questions about our privacy practices or concerns about confidentiality, please contact us at info@kindnesssd.org. We may update this policy occasionally and will notify you of any changes that affect how we handle your information.
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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

Please fill out our ROI form: https://form.jotform.com/Kindness_Initiative/roi-form-authorized-persons
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Member Application Form

Part 5: Privacy Policy