BMC Pathways Application Year 1

BMC Pathways Application Year 1
In Partnership with

Dr. Walter Brown, APC
This program is sponspored by
The BMC Pathways program focuses on enhancing math skills and promoting mental health within the community. This 85-100 hours initiative that serves at-risk youth and young adults aged 14 to 24, offering them essential support and resources. Participants, together with their parents or legal guardians, collaborate with Dr. Walter Brown, his staff, and math mentors from the Black Math Collective to strengthen their math abilities. The program aims to prepare students for future careers, with a potential incentive awarded upon successful completion.

Space in this program is limited.
This notice ensures that applicants are fully informed about how their information will be handled and the limits of confidentiality, aligning with best practices in mental health services. We take your privacy very seriously. Any personal information you share with us, including but not limited to your name, contact information, medical history, and mental health details, will be kept strictly confidential. This information is protected under applicable privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA). It will not be disclosed to any third parties without your explicit consent except as required by law. By proceeding with this application, you acknowledge that you have read and understood this confidentiality notice and agree to the terms mentioned above.
Participant Information
Full Name*

First NameLast Name
Gender*
Date of Birth*

MonthDayYear
Date
Participant's Email*
example@domain.com
Phone Number*
Please enter a valid phone number.
Participant's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
City*
Zip Code*
What is the name of your current School?*
Would you like to pursue higher education?*

Community CollegeUniversityTrade School
Which organization referred you to BMC pathways?*

HACLAFremont High SchoolDCFSDTDOther
Section I: Math Survey
How do you feel about Math?*

Love itJust okayNeed some helpNot a fan
How do you feel about Fractions?*

I understand fractionsI don't understand fractionsI am familiar with fractions
Do you prefer working alone, with a group or with a tutor ?*

AloneGroupTutor
Do you think it is important to be part of a community that values Math?*

YesNoMaybe
What do you enjoy most about Math?*
How do handle challenges or frustrations when working on math problems?*
Do you have any concerns about your basic math skills or specific subjects?*
Section II: Mental Health Survey
What has been your biggest challenge in your life so far?*
Do you believe everyone experiences some type of trauma in their life?*

YesNo
Have you ever received psychological counseling before?*

YesNo
Have you ever done group counseling?*

YesNo
Do you feel the counseling helped with your issues?*

YesNo
What would be your primary reasons for enrolling in BMC Pathways?*

To improve my math skillsTo consider a STEM career pathTo stay out of the systemTo improve my mental healthTo benefit my life
Please describe yourself with one word*
Section III: Parent/Guardian Contact Information
Full Name*

First NameLast Name
Cell Phone*
Please enter a valid phone number
Relationship*
Contact Email*
example@domain.com
My address is the same as student's address
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Section V: Emergency Contact Information
Full Name*

First NameLast Name
Cell Phone*
Please enter a valid phone number
Relationship*
Contact Email*
example@domain.com
Section VI: Parental Consent for Photography and Participation in Evaluation Studies
Photography*

Yes, I grant permission for my child to be photographed or videotaped as part of their participation in the Black Math Collective (BMC) programming.No, I do not give permission for my child to be photographed or videotaped as part of their participation in the BMC program.Yes, I do grant permission to be photographed or videotaped during the participation in the BMC program.No, I do not grant permission to be photographed or videotaped during the participation in the BMC program.
Media/Photo Release*

I grant permission for my child to be photographed or videotaped as part of their participation in the BMC program. I also authorize the use of their photo or image in publications, promotional materials, and other media related to the BMC program.I do not grant permission for my child to be photographed or videotaped during their participation in the BMC program. Additionally, I do not authorize the use of their photo or image in any publications, promotional materials, or media related to the BMC program.
Media Release of Information*

Yes, I give permission for my child to participate in evaluation studies conducted by BMC. This may include observations of my child during regular program activities, anecdotal notes on their progress, and the use of developmental assessments and other evaluation results. I understand that all information will be treated confidentially, and my child’s full name will not be used in any public reports, except in confidential reports required by the state or school district.No I do not give my permission for my child to participate in evaluation studies for BMC.
Community Release of Information
I hereby authorize full communication regarding my progress within Third Party Administrator (TPA) service providers, including but not limited to: my demographic information, justice system involvement, service assessments, services information, and myprogram outcomes on a need to know basis between the following agencies:

 Los Angeles County (JCOD)
 Amity Foundation TPA Project
 TPA Funded Community-Based Program (CBP) of My Enrollment
 The Black Math Collective

 Counseling Services Inc.

The purpose of this disclosure is to coordinate service provision and all data associated with CFCI funding.

I understand that my records are protected under the federal regulations governing Confidentiality of the Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and HIPAA and cannot be disclosed without my written consent unless otherwise provided for in the regulations.
Expiration if mandated into TPA community services-This consent will expire automatically when there has been a formal and effective termination of services by the program provider. Expiration if TPA services are voluntary- If I sign up for TPA services without legal mandates to do so, this release will expire thirty days after I complete the TPA funded program and/or services, successfully or unsuccessfully. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it. I also understand that recipients of any information disclosed in accordance with Part 2 of Title 42 CFR or HIPAA may re-disclose it only in connection with their official duties.
Signature*

Powered by Jotform SignClear
I understand that photographs, slides and videos will be used for educational purposes, our official website, fundraising and/or to promote BMC's mission.
Please read the RELEASE AND WAIVER OF LIABILITY FOR ALL AFTER SCHOOL CLASSES AND PROGRAMS.
I have read the RELEASE AND WAIVER OF LIABILITY FOR ALL AFTER SCHOOL CLASSES AND PROGRAMS.*

YesNo
PARTICIPANT: In signing this Acknowledgement of Risk and Waiver of Liability I hereby acknowledge and represent that I am of legal age and have read this document in its entirety, understand it, and sign it voluntarily.
Signature*

Powered by Jotform SignClear
Participant's Full Name*

First NameLast Name
Date*

MonthDayYear
Participants under 18 years of age, or those not legally competent, must sign above and obtain a parent or legal guardian’s signature below. I certify that I am the parent or legal guardian of the participant named above. On behalf of myself and any others who may represent the participant, I have read and understand the agreement, consent to its terms, and sign voluntarily. I acknowledge that my dependent and I agree to these terms, consent to participation, and authorize necessary medical treatment. I further agree to hold harmless, indemnify, and defend BMC and its staff from any claims or demands my dependent may have.
Signature*

Powered by Jotform SignClear
Parent/Guardian Full Name

First NameLast Name
Date

MonthDayYear
Should be Empty:

BMC Pathways Application Year 1

In Partnership with

Community Release of Information