Support Role Interest Form Kentucky Family to Family Health Information Center (KY F2F HIC)
Involvement in a Support Role for KY F2F HIC, within the Office of Children with Special Health Care Needs.
Legal First Name
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Legal Last Name
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How did you hear about KY F2F HIC?
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Family/Friend
KY F2F HIC staff member
Office for Children with Special Health Care Needs staff
Internet Search
Social Media
Other
Ky Family-to-Family Health Information Center is a peer-to-peer program. As outlined in the federal grant guidelines, in order work within Family-to-Family programs, you must be a parent/caregiver/guardian to a child with special health care needs with lived/living experience.
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Yes, I am a parent/guardian/caregiver of a child with special health care needs.
No, I am not a parent/guardian/caregiver of a child with special health care needs.
When working within a Support Role for Kentucky families who are trying to navigate the complex systems with their child/children, your role is to support the families in various ways. Do you feel you have a strong knowledge base to be able to assist families navigating insurance, school needs, researching information, and appropriate advocacy during medical appointments?
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Yes
No
With training, yes.
Please select all languages that you speak fluently.
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English
Spanish
Japanese
Korean
German
Other
Date you could begin in a Support Role
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Month
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Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Email address
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Phone number
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Street Address
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City
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State
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Zip Code
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Daytime availability
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Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays
Evening Availability
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Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays
Please select the average number of hours you could provide KY F2F HIC per week
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1-2
3-4
5-6
7-8
9 or more hours
How would you be able to provide support to families?
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In person at one of the OCSHCN offices (Paducah, Owensboro, Bowling Green, Louisville, Elizabethtown, Somerset, Lexington, Barbourville, Hazard, Prestonsburg, Morehead)
By video call (Zoom or Teams)
Phone
Email
Please describe how your child with special health care needs has impacted your life.
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What type of support do you feel you could provide other families going through something similar?
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Please select the topics you feel you have a working knowledge of:
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Waiver programs
kynect benefits/insurance
IEP/504 plans
Making calls and connections to providers and resources
Support Groups
Navigating complex medical needs
Advocacy with providers and medical staff
Americans with Disability Act (ADA)
Other
Please mark any of the following you have any level of experience with:
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Working with children/youth with special health care needs
Working with parents of children/youth with special health care needs
Peer-to-Peer Support
Parent Advocacy
Legislation around children/youth with special health care needs
Marketing/Content Creation
Event/Outreach Planning
Event/Outreach Day Of/Communication/Working with Attendees
None
Other
As part of our Onboarding, you will be required to complete various trainings online as well as complete forms online. You may also provide support to families via video calls. Do you have reliable access to a computer and internet with a video camera?
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Yes
No
Sometimes
You will be required to document your time working within KY F2F HIC, utilizing an online form by computer or on your phone. Do you have access to complete an online form?
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Yes
No
Maybe
You may be asked to travel to an office for family support or an event. Do you have the ability to travel with reliable transportation?
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Yes
No
Sometimes
Please list any accommodations you may need to help support your involvement with KY F2F HIC.
You may be required to complete a background check due to the nature of your role. Do you consent to a background check if required?
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Yes
No
We are able to provide reimbursement for Support Parents. In order to provide this, registering for a Vendor Number with the state is required which includes completing a W9 and a Vendor Application that would be provided to you.
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I understand a W9 and an Affidavit for Contractors will be required for roles that offer reimbursement.
Please select the Support Roles you would be interested in. They may not all be available at all times.
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Support Parent (1:1 assistance with families for families, Reimbursement available)
Parent Volunteer (Events and Trainings, no reimbursement)
Event Coordinator (Reimbursed role)
Support Parent Lead (Reimbursed role)
Please list any special health care needs/conditions that you are familiar with (Behavioral, brain injury, genetic, hearing, sight, etc).
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Please list any experience you have in Support or Advocacy roles. Please write "none" if no experience.
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Please provide any additional information you think would be helpful.
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