EmpowerOKC Youth under 18 Registration and Policy Acknowledgements

Family Information
Parent/Guardian #1

First NameLast Name
Middle Initial
Preferred Name (if different)
Relationship to child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Best way to contact
Best time to contact
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2

First NameLast Name
Middle Initial
Preferred Name (if different)
Relationship to child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Best way to contact
Best time to contact
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Emergency Contact #1 Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to child
Is this person authorized to pick up the child?
Emergency Contact #2 Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to child
Is this person authorized to pick up this child?
What are the ages of the children that this client that is seeking services have?
Please list any other individual who is authorized to pick up the child that is seeking services in this registration. (include full name and relationship to the child)
Signature of person completing this Youth Form: Should be the parent or guardian.
Relationship to youth
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Lilyfield Media Release
I, name of parent*, give Lilyfield permission to use photographs, quotes, and information regarding our family for public relation publication. We understand this publication may be made available on the Lilyfield website, publications Lilyfield events, and in other public venues.
We hereby waive the right to inspect or approve the images, quotes or the publication prior to any form of usage. We understand the images may be modified to be used as design elements.
By signing this agreement, we are releasing all rights to any images, quotes and the publication.
Indicate your selection below by circling the desired response:
You may use our first names
You may use our last name
You may use photos of our children
You may use our children's names
Client Name

First NameLast Name
I certify, by signing below, that we are both of legal age, 18 years or older or we are the parent or legal guardians of the identified minor. We have read this agreement and fully understand the contents herein.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Medical Release Form
Client Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #1 Name

First NameLast Name
Relationship to child
Daytime Phone
Please list all individuals authorized to pick up your child
Please disclose any medical conditions or special needs for the child:
List all medications the child takes and directions for usage:
List any allergies your child has:
In the event of an emergency, what hospital would you like your child transported for care?
Name of child's physician?
Is there any other information Lilyfield should be aware of that may affect your child's ability to participate in our program?
If yes, please explain:
Medical

The child listed above has my permission to participate in all Lilyfield Camp activities. I give permission for the designated person to administer over-the-counter or prescription medication as directed. I hereby, and for my heirs, executors, and administrators, assigns and all legal guardians, waive and release any and all rights and claims of any nature. I may have against Lilyfield, its directors, employees, volunteers, students, or cooperating entities for and against any and all injuries and damages of any nature, which my child may suffer while taking part in any Lilyfield activities. In case of medical emergency, after every reasonable effort has been made to contact me or the child’s physician, I hereby give my permission to the Emergency Medical personnel contracted by Lilyfield to secure treatment for, hospitalize and order injections, anesthesia or surgery for my child. I also authorize Lilyfield to provide a copy of this form to the proper medical personnel for purposes applicable to the activities, I agree to pay all expenses incurred in such emergency treatment.
Parent/Guardian Full Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Adverse Childhood Experience Questionnaire (ACE-Q)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian #1

First NameLast Name
Relationship to child
Many children experience stressful life events that can affect their health and wellbeing. The results from this questionnaire will assist your child’s doctor in assessing their health and determining guidance. Please read the statements below. Count the number of statements that apply to your child and write the total number in the box provided.

Please DO NOT mark or indicate which specific statements apply to your child.
1) Of the statements in Section 1, HOW MANY apply to your child? Write the total number in the box.
Section 1. At any point since your child was born…
- Your child’s parents or guardians were separated or divorced
- Your child lived with a household member who served time in jail or prison
- Your child lived with a household member who was depressed, mentally ill or attempted suicide
- Your child saw or heard household members hurt or threaten to hurt each other
- A household member swore at, insulted, humiliated, or put down your child in a way that scared your child OR a household member acted in a way that made your child afraid that s/he might be physically hurt
- Someone touched your child’s private parts or asked your child to touch their private parts in a sexual way
- More than once, your child went without food, clothing, a place to live, or had no one to protect her/him
- Someone pushed, grabbed, slapped or threw something at your child OR your child was hit so hard that your child was injured or had marks
- Your child lived with someone who had a problem with drinking or using drugs
- Your child often felt unsupported, unloved and/or unprotected
Number of statements in section 1 that apply to the child
2) Of the statements in Section 2, HOW MANY apply to your child? Write the total number in the box.
Section 2. At any point since your child was born…
- Your child was in foster care
- Your child experienced harassment or bullying at school
- Your child lived with a parent or guardian who died
- Your child was separated from her/his primary caregiver through deportation or immigration
- Your child had a serious medical procedure or life threatening illness
- Your child often saw or heard violence in the neighborhood or in her/his school neighborhood
- Your child was often treated badly because of race, sexual orientation, place of birth, disability or religion
Number of statements in section 2 that apply to the child

The following 5 sections are notices about Lilyfield confidentiality, policies and procedures. Please read them carefully and sign the acknowledgement page.
Informed Consent for EmpowerOKC Services
Services Provided

Empower provides the Check & Connect educational intervention for student engagement and after school programming. The Check & Connect intervention pairs a student and their family with a caring adult called a “Connector” to support engagement in school through relationship building, problem solving, and capacity building. Connectors may be AmeriCorps members or volunteers. After School, school break, and summer programming include social and emotional learning, skill building, homework help and/or tutoring. Trauma informed methods are used to guide services. Lilyfield does not provide transportation to clients. No service will be provided without parent/guardian consent. EmpowerOKC services are voluntary and there is no cost to you or your family. You are free to limit or end services at any time.

Confidentiality

Lilyfield will keep the information you share confidential, unless we have written consent to disclose certain information. There are important exceptions to this rule. In some situations, we are required by law or by the guidelines of professional rules and regulations to disclose information whether or not we have your permission which are as follows:
• You tell us that you plan to cause serious harm or death to yourself, and we believe you have the intent and ability to carry out this threat in the near future.
• You tell us that you plan to cause serious harm or death to someone else who can be identified, and we believe you have the intent and ability to carry out this threat in the very near future.
• You tell us that you are being physically, sexually or emotionally abused or we have a reasonable suspicion that a minor under the age of 18 is the victim of abuse or neglect. We are required by law to report the abuse to the Oklahoma Department of Human Services.
• Your information regarding counseling is subpoenaed by the court. We may be required to disclose information to the court.

Crisis Response

Empower AmeriCorps members and volunteers are not mental health professionals and therefore not equipped to respond to mental health crises, including but not limited to suicidal thoughts or ideations. Clients served by EmpowerOKC who demonstrate symptoms of a mental health crises will be referred to appropriate mental health resources. If a child is experiencing a mental health crises, the following resources may be accessed.
• 911 Emergency
• Oklahoma Department of Mental Health Crisis ReachOut Helpline 1-800-522-9054
• Crisis Text Line Text HELLO to 741741
• National Adolescent Suicide Helpline 1-800-621-4000

Behavior Support Management Acknowledgement
Lilyfield cares about the safety of Empower program participants. We are committed to maintain a safe environment for all clients that we serve. However, we know at times that the individuals we serve may have extreme reactions and on occasion may exhibit out of control behavior.

In order to help prevent out of control behavior, Lilyfield works to facilitate a supportive and safe environment in which participants are encouraged to practice self-care. If we notice that an Empower participant starts to show early signs of agitation that may lead to out of control behavior, we will first redirect the participant to use strategies to reduce anxiety such as taking a break, deep breathing, getting a drink of water, or talking to a supportive adult. If needed we will halt the session and ask a school staff member or other Lilyfield staff member to participate in helping him/her regain control.

Lilyfield strictly prohibits staff from engaging in manual or mechanical restraints or the use of seclusion to manage out of control client behavior.
Other prohibited actions or interventions include:
a. corporal punishment;
b. the use of aversive stimuli;
c. interventions that involve withholding nutrition or hydration or that inflict physical or psychological pain;
d. the use of demeaning, shaming, or degrading language or activities;
e. forced physical exercise to eliminate behaviors;
f. unwarranted use of invasive procedures or activities as a disciplinary action;
g. punitive work assignments;
h. punishment by peers; and
i. group punishment or discipline for individual behavior.

In the event that none of the strategies work, the Lilyfield staff member will notify a school staff member who will then take responsibility for managing the out of control behavior at that time. If needed, the participant will be assessed and referred for mental health services.

Lilyfield Client Rights
It is the policy of Lilyfield, Inc. to provide all clients with the following rights:

1. To access Lilyfield’s services during our office hours of 8:30 a.m.-5 p.m. Monday-Friday. Evening appointments are available by appointment only.
2. To be treated with dignity and respect.
3. To receive services in a non-discriminatory manner.
4. To be free to express and practice spiritual and religious beliefs.
5. To be informed of Lilyfield’s policies and procedures which relate to them and/or their child’s care and any changes made to these policies and procedures.
6. To receive consistent enforcement of program rules and expectations.
7. To experience an environment free of neglect or abuse of any nature, including but not limited to sexual, physical, or verbal.
8. To receive services in a manner that is non-coercive and that protects the person’s right to self- determination.
9. To have personal information protected from unauthorized disclosure without their written consent to release their information except as required by law to protect a child or someone else from physical danger, abuse or neglect, to respond to a legal subpoena, or to report evidence related to criminal behavior.
10. To expect phone calls and other correspondence, such as letters or e-mails, to be returned in a timely manner.
11. To have access to appropriate support services for themselves and/or their child.
12. To have the correct contact information for the agency and the primary worker assigned to them.
13. To file a grievance and be informed of the process for filing a grievance.
14. To be provided with prompt, competent, and appropriate treatment and to allow other individuals of the client's choice to participate in the treatment.
15. To receive services that are respectful of, and responsive to, cultural and linguistic differences.
16. To receive accommodations, as appropriate, related to the visual, auditory, motor abilities, or written and oral communication needs of the client as necessary.
17. To refuse any service, treatment, or medication unless mandated by law or court order; and
18. To be informed of the consequences of such refusal, which can include discharge
Notice of Grievance Rights
Lilyfield’s wants to ensure that all clients are ensured fair consideration of complaints made by clients, including children, and guarantee a quick resolution to any complaint. You have a right to file a grievance, receive written response to your grievance and to appeal if you are not satisfied with the response you get. You have a right to report allegations of abuse, neglect, and mistreatment. If anyone attempts to deny you these rights or causes you problems in filing a grievance, contact your Grievance Coordinator immediately.

Who May File a Grievance:

Any client receiving services through Lilyfield’s Empower Program or any person interested in this client’s welfare. (This could be your parent/guardian, foster parent, mentor, or attorney)

What Complaints Are Considered:

The complaint may be about any policy, rule, decision, behavior, and action or condition made or permitted by Lilyfield employees.

How to File a Grievance:

Write your complaint down and include how you wish to resolve this problem. If you are unable to write, then your worker will help you write out your complaint. You have 30 working days from the date of your complaint to file your grievance. If your complaint is against a Lilyfield employee, you may wish to contact the Empower Coordinator or Director of Lilyfield for help with the complaint.

What Happens Next:

You will receive a written response within 10 working days after turning in your grievance. The Grievance Coordinator will meet with you to discuss the response to your grievance. If you are unhappy with their response, you may ask for a second level review of your complaint.
Should you wish more information about your right to file a grievance and the procedures involved, please contact Tiffany Hooper at the following telephone number: (405) 216-5240.

Technology Based Service Disclosure
When and How They Are Offered:

In the event of inclement weather, illness or sickness, lack of transportation, site closure or additional unforeseen barriers, Lilyfield may offer technology-based services. Lilyfield’s services are intended to be received in person. An attempt to reschedule in-person services will be made first. Personnel and staff will communicate on an ongoing basis to assess the need for technology-based services. The client is responsible for communicating any change in barriers or challenges preventing access to technology-based services.
Personnel will explain the program before the services begin. Client participation in this is totally voluntary and may decide to stop services at any time.

Digital Confidentiality:

The safety of our clients and their families is a top priority at Lilyfield. Please keep in mind that technology-based services are not guaranteed to be secure. Virtual services will be provided in confidential locations, using Microsoft Teams. The client understands that, while secure and compliant platforms are used, there may be an increased security risk associated with internet usage. It is understood that clients should use a secured internet connection and use the program in a private place where others cannot overhear confidential information. The standards for group confidentiality during in-person services are also expected to be upheld during virtual sessions. Lilyfield prohibits taking photographs, video recordings, screenshots, and sharing any personal information of other participants. Lilyfield will make every attempt to ensure client privacy and confidentiality are protected but acknowledges that other parties may not adhere to the same standard. When receiving services over video, anyone can see who is in the room at the other site.

Crisis Response:

Lilyfield staff should ascertain the client’s location at the beginning of each session, if possible, to best respond in a crisis. If a client experiences a crisis while teleservices are being used:
a. Find out the location of the client if not already known. b. Call 911 if the client presents an imminent danger to self or others c. Call client’s parent/guardian if client is a minor d. Provide appropriate referrals for the caregiver to ensure safety. Referral services may include referrals to the Emergency Room, the Oklahoma County Children’s Mobile Response Unit, and coordination with local law enforcement.

Acknowledgement of Lilyfield Policies and Procedures

Check & Connect, Kids Club, and Youth Club
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I have read and understand the Lilyfield Informed Consent. I consent to receive services.
I have received, read, and understand the Lilyfield Behavior Support Management Acknowledgement.
I have received, read, and understand the Lilyfield Notice of Grievance Rights.
I have received, read and understand the Lilyfield Client Rights.
I have received, read and understand the Lilyfield Technology Based Service Disclosure.
Authorized signature if client is a minor
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Authorized person
Relationship to minor
Signature of OKDHS Staff
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Youth Registration

Client Information

Client Characteristics

Family Information

Emergency Contact Information

Lilyfield Media Release

Medical Release Form

Adverse Childhood Experience Questionnaire (ACE-Q)

Informed Consent for EmpowerOKC Services

Behavior Support Management Acknowledgement

Lilyfield Client Rights

Notice of Grievance Rights

Technology Based Service Disclosure

Acknowledgement of Lilyfield Policies and Procedures