Hello and thanks for you interest in Village in the Ville!

How This Form Works

Through this form you'll provide us the basic information we need from you to join Village in the Ville and sign our requiste policy forms. There is also a section of optional information we request to help us guage the success of our program and apply to grants. 

Once you have completed this form, Village in the Ville's Program Director, William Jones-Kline will reach out to meet. This meeting is a brief one-on-one where you can introduce yourself and learn everything you'll need to know about Village in the Ville. 

More Information About Village in the Ville

Village in the Ville is a grassroots, member-driven community organization created for neighbors by neighbors. We are a program of the Clintonville-Beechwold Community Resources Center that provides services, engagement, and connection to adults aged 50+ so that they can better age in community. 

Our Mission

To cultivate a community of older adults rooted in connectedness and compassion that celebrated diversity and promotes reciprocal volunteer assistance. 

Our Vision

A network of neighbors flourishing in their homes and community as they age. 

Our Core Values

Collaboration. We together with members, volunteers, and community partners to share opportunities, skills, and knowledge with the understanding that our strength comes from the unity of our diverse experiences and insights. 

Flexibility and Experiementation. We bend without breaking to remain productive, innovative, and agile in times of ease and crisis. We welcome all viewpoints and ideas with openness and curiosity to promote a healthy community. 

Reciprocity. We are bolstered by the understanding that all of us have something to give and that all of us have something we need. We encourage all participants to dig into the progound joy of caring for their neighbors and in return receiving care. 

Grace. We strive to meet the ever-changing social, emotional, cognitive, and physical needs of our members and believe that we all - members, volunteers, and staff alike - deserve and benefit from compassion and a sense of belonging.

Participation Agreement 

By signing below, I hereby acknowledge that I have voluntarily decided to participate in the Clintonville-Beechwold Community Resource Center’s Village in the Ville program and confirm my understanding and agreement to the following:

Informed Consent 
I acknowledge and confirm that I have received and reviewed Village in the Ville’s “Community Handbook” and/or have participated in Village in the Ville’s “MemberKit Orientation.” I am confident that I understand the various aspects of participating in Village in the Ville, including but not limited to receiving services, attending social and educational events, membership dues, and program policies. 

Specific Rights 
I recognize that by receiving in-home services from a program funded through the Older American Act that I have specific rights. I acknowledge and confirm that I have been informed of and am confident that I understand these rights, including:  

• The right to be fully informed in advance about each in-home service provided and any change in such service that may affect the well-being of the individual; and to participate in planning and changing an in-home service. 
• The right to voice a grievance with respect to such service that is or fails to be provided, without discrimination or reprisal. 
• The right to confidentiality of records. 
• The right to have my property treated with respect. 
• The right to voluntarily donate towards the cost of services however I will not be denied based on my ability to donate. 
• The right to participate in Cost Share related to Adult Day service, Homemaker service, Personal Care service and Transportation service however I will not be denied based on my decision to participate.

Participation Eligibility 
I confirm that I meet the eligibility requirements for participating in Village in the Ville. I understand that there may come a time when my needs exceed the services Village in the Ville can provide. I recognize that Village in the Ville has service limitations and grant the right to the Clintonville-Beechwold Community Resource Center to refer me to other programs once my needs have exceeded Village in the Ville’s service limitations.  

Program Policies 
I accept all policies outlined by Village in the Ville and agree to abide by the expectations set forth therein. I understand that failing to do so may result in intervention, mediation, and termination of my membership. I further grant the right to the Clintonville-Beechwold Community Resource Center to terminate my participation in Village in the Ville if it is determined that my conduct is detrimental to the best interest of Village in the Ville. 

Medical Condition and Care 
I understand that I am responsible for knowing my physical condition and making my own decision about my participation in Village in the Ville. I authorize Village in the Ville to provide me with first aid, emergency medical assistance, and transportation if I get hurt while participating in Village in the Ville. I understand that I am responsible for any costs related to my medical treatment and transport, and that Village in the Ville does not provide health, medical, disability, or other insurance.  
I further understand that Village in the Ville staff and volunteers are trained to engage with and support members but are not medical, mental health, or social work professionals. I recognize that their support is not the advice of a professional. 

Acceptance of Risk and Release of Liability 
I understand that my participation in Village in the Ville has risks and accept full responsibility for the foregoing risk of injury, permanent disability or death. I further understand and acknowledge that despite careful planning and supervision, persons involved may sustain fatal or serious injury, property damage, or severe social and/or economic loss as a consequence of not only their own actions, inactions, or negligence, but the actions, inactions, or negligence of others, weather conditions, conditions of equipment, language barriers, differing social cultures, and laws. There may also be other risks not known to me or not foreseeable at this time. 

In consideration of the opportunity to participate in Village in the Ville, I release and discharge the Clintonville-Beechwold Community Resources Center, its officers, employees, and agents from all liability defined herein arising out of or in connection with my participation in Village in the Ville. For the purpose of this Agreement, liability means all claims, demands causes of action suits or judgements of any kind (including court costs and attorney’s fees) that I, my heirs, executors, administrators, assignees, or any other person or entity may have against the Clintonville-Beechwold Community Resources Center because of my death, personal injury, illness, or for loss arising out of the sole negligence or willful misconduct of the Clintonville-Beechwold Community Resources Center. I hereby agree that this Agreement shall be constructed in accordance with the laws of the State of Ohio.  

Indemnification 
I agree not to sue the Clintonville-Beechwold Community Resources Center and hold harmless, defend, and indemnify the Clintonville-Beechwold Community Resources Center from any and all liability as described above that may occur due to my participation in Village in the Ville. 

Photo Release

By signing below, I hereby grant the Clintonville-Beechwold Community Resources Center permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration.

I understand and agree that all photos will become the property of the Clintonville-Beechwold Community Resources Center and will not be returned.

I hereby irrevocably authorize the Clintonville-Beechwold Community Resources Center to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

I hereby hold harmless, release, and forever discharge the Clintonville-Beechwold Community Resources Center from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.