Youth Event Registration TCFH/BOTS 2024-2025

TCFH & BOTS Waiver/Release/Intake Form

Youth Drop-Off Event Waiver/Intake (Creative Nights, Zoo Event, Photography Workshop & Others) For tweens/teens 10-18 years old.
Tell us which event/program you are registering your 10-18 year old for today: (all of the below are drop-off events for youth 10-18 only). Drop off locations vary based on event. Creative nights are held at 7811 Farnam Drive.*

Fall Creative Nights - Music, Art, Writing - Weekly on TUESDAY evenings, starting November 6th. Time: 6-7:45pm (FREE) at 7811 Farnam Drive in OmahaRise and Vibe: An art-based storytelling workshop at Kaneko Center downtown Omaha - December 8th 11am-3pm
Caregiver/Guardian Full Name*

Caregiver First NameCaregiver Last Name
Primary Caregiver Phone Number*

Area CodePhone Number
Secondary Caregiver Phone Number (optional)

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address*
Ethnicity*
Are you of Hispanic, Latino, or Spanish origin?*

YesNoPrefer not to disclose
Annual household income (This information is used grant reporting and will be kept confidential. Demographics will only be reported anonymously and separate from any identifying information such as name.)*

Below $26,500$26,501-$35,000$35,001-$50,000$50,001-$75,000$75,001-$150,000Over $150,000I prefer not to disclose
Information about the person who died

Please tell us about your child's special person(s) below
Name of person who died*

Person Who Died First NamePerson Who Died Last Name
Death date*

MonthDayYear
Date
Age at death (person who died)*
Cause of death*

Alzheimer's DiseaseAccidentAccidental OverdoseCar/Motorcycle/ATV AccidentCancerCOVID 19/COVID 19-RelatedDiabetes-relatedDrowningHeart DiseaseHeart AttackHomicideKidney DiseaseLong-term Substance AbuseMiscarriageMurder-SuicideRelated to genetic disorder/diseaseSIDSStillbirthStrokeSuicideSurgery ComplicationsUnintentional Injury/AccidentUnknownOther
Youth Allergies
We may offer snacks and drinks at events. Please list any/all allergies or dietary needs. If your child has severe allergies, please be sure they have an EpiPen with them in case of emergency.*

Egg AllergyNut AllergyDairy AllergyGluten AllergySoy AllergyVegetarianVeganNONEOther
Health & Mental Health History

Please note that we are not therapists or counselors. We offer peer support and trained staff, volunteers, facilitators. If your child exhibits behaviors that go against our policies/expectations/group norms, we may call the caregiver listed above, and if they do not answer, we will call the emergency contact on file. Please make yourself available by phone/text during while your child(ren) are in our care.
Does/do your child(ren) suffer from these? (Please check all that apply)*

AnxietyDepressionAngerAlcoholismStressDrug AddictionCommunication IssuesEating DisorderParenting IssuesAdoption IssuesAbandonment IssuesPost Traumatic Stress DisorderVictim or witness of domestic violenceCutting/self-harmSuicide attempts or ideationOther
If you marked any of the above, please explain more here. List any physical or mental health related conditions/concerns we should be aware of including any accommodations needed during groups: (including but not limited to anxiety, suicidal ideation, ADHD, use a wheelchair, difficulty writing, developmental delays, etc.) If none, please type N/A below*
Child(ren) Information

Please fill out the following for each child (age 10-18) who will be attending group. This is collected for record keeping and reporting. By disclosing the following demographics, you are helping us apply for grants/funding that keep our programs free and/or accessible to everyone regardless of their ability to pay.
Child's name*

Child 1 First NameChild 1 Last Name
What should we call them if different than above? (preferred name or nickname) *
Child 1 Preferred name
Child Birth Date: *

MonthDayYear
Child 1 Birth Date
Child's Current Age:*
Child 1 Age
Some programs are broken out by developmental age. Is child developmentally the age listed above? Does this child have an IEP At School? Please let us know how we can best support them in a group setting. These events are for those with a developmental age of 10-18. *
Child 1 More information
School*
Child 1 School
Grade*
Child 1 Grade
Gender/Gender Identity*
Child 1 Gender Identity
Pronouns*
Child 1 Pronouns
Ethnicity*
Child 1 Ethnicity
Is this child of Hispanic, Latino, or Spanish origin?*

YesNoPrefer not to disclose
Photo of attending youth

Browse Files
help us put a face to the name by uploading a recent photo of the attending youth Cancelof
Deceased relationship to child: *
Child 1 Relationship with Deceased
How old was the child when this person died? *
Child 1 Age When Person Died
Was the child on scene when the person died/a witness to do the death?
Child 1 Scene
Is there anything you'd like us to know about this child or their struggles since the death of their special person(s)? *
Child 1 Additional Information
Child(ren) Information

Please fill out the following for each child (age 10-18) who will be attending group. This is collected for record keeping and reporting. By disclosing the following demographics, you are helping us apply for grants/funding that keep our programs free and/or accessible to everyone regardless of their ability to pay.
Child's name

Child 2 First NameChild 2 Last Name
What should we call them if different than above? (preferred name or nickname)
Child 2 Preferred name
Child Birth Date:

MonthDayYear
Child 2 Birth Date
Child's Current Age:
Child 2 Age
Some programs are broken out by developmental age. Is child developmentally the age listed above? Does this child have an IEP At School? Please let us know how we can best support them in a group setting. These events are for those with a developmental age of 10-18.
Child 2 More Information
School
Child 2 School
Grade
Child 2 Grade
Gender/Gender Identity
Child 2 Gender Identity
Pronouns
Child 2 Pronouns
Ethnicity
Child 2 Ethnicity
Is this child of Hispanic, Latino, or Spanish origin?

YesNoPrefer not to disclose
Photo of attending youth

Browse Files
help us put a face to the name by uploading a recent photo of the attending youth Cancelof
Deceased relationship to child:
Child 2 Relationship With Deceased
How old was the child when this person died?
Child 2 Age When Person Died
Was the child on scene when the person died/a witness to do the death?
Child 2 Scene
Is there anything you'd like us to know about this child or their struggles since the death of their special person(s)?
Child 2 Additional Information
Waivers
Artwork, Photographs, and Video Images

I authorize The Collective for Hope and Band of the Strong and/or assignees or licensees to use art, photographs and/or video images of my child for reproduction for promotional, illustrative, marketing, social media, or educational purposes. I understand that the above activities will not result in any profit, and that I will not receive any monetary compensation. Permission is granted to make changes or alterations and to use my child’s name or a fictitious name in editorial works or advertising. I understand that The Collective for Hope and Band of the Strong takes photographs of the members and families during programs and may share the images in program communications. I give permission and understand that my child and family may be photographed and/or videotaped at The Collective for Hope and Band of the Strong programs and events.

Emergency Medical Treatment Release

I agree to have my child receive any emergency medical services deemed necessary by the authorities in charge. I understand that the resulting expenses will be my responsibility as the child’s parent/guardian. I further agree to release, discharge and indemnify The Collective for Hope, Band of the Strong, its Officers, Board of Directors, Employees and Agents from any and all liability, damages, claims or causes of action, arising out of or in any way connected to the administration of emergency medical services.

The Collective for Hope Outings/Activities Release

I agree to release and forever discharge The Collective for Hope, Band of the Strong, its Officers, Board of Directors, Employees and Agents, and all vessels and facilities owned and/or operated by The Collective for Hope (hereinafter “Released Parties”) from any and all liability, damages, claims or causes of action, arising out of or in any way connected with the minor’s participation in The Collective for Hope and Band of the Strong outings and activities. I further agree to indemnify the Released Parties and hold them harmless from any liability, damages, claims, or causes of action made or brought by the said minor or by anyone on behalf of the minor as a result of or in any way connected with the minor’s participation in The Collective for Hope and Band of the Strong outings and activities. The undersigned acknowledges that the outings and activities addressed by this release are completely VOLUNTARY.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself and/or my child(ren) (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my attendance or my child(ren)’s attendance at in-person events with The Collective for Hope and Band of the Strong. On my behalf and/or on behalf of my child(ren), I hereby release, covenant not to sue, discharge, and hold harmless The Collective for Hope, Band of the Strong, its employees, directors, contractors, program partners, volunteers, agents, and representatives of and from the claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of The Collective for Hope, Band of the Strong, its employees, directors, contractors, program partners, volunteers, agents, and representatives, before, during, or after participation in any in-person appointments with The Collective for Hope.

Lost or Stolen Items

The Collective for Hope, Band of the Strong, its employees, directors, contractors, program partners, volunteers, agents, and representatives will not be responsible for damaged, broken, lost or stolen items of any kind. Valuable items should be left at home.
Parent/Guardian/Caregiver Signature (typed)*
Signature*

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Today's Date*

MonthDayYear
Date
Authorized for drop-off / pick-up

Please list all persons authorized to drop and pick up youth from activities
Name*

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Comments about drop-off/pick-up?
Confidentiality

& Mandatory Reporting
Participant’s Role
I can share only what I said, what I felt, or what I learned. I will be respectful of other group members by not sharing what other members have shared, felt, or how they have acted. I may not talk about another group member outside of the group itself.

Facilitator/Staff Role

We respect each and everyone's right to privacy and confidentiality and we shall make sure to maintain it that way. However, please understand that this is not absolute and is limited to provide for by law. Everyone in the state of Nebrasksa is a Mandatory Reporter. Confidentiality exceptions while rare are as follows: Threatening one's self or another that may result in physical harm;An act of physical or emotional abuse against a child or any person;Sexual abuse against a child where the child is living with the abuser;Whenever we are summoned by court order to disclose information against a participant.
Expectations/Communications

We are not counselors or therapists and we do expect youth to abide by our policies and group norms/"rules"
If your child exhibits concerning behaviors or act in a way that goes against our policies/expectations/group norms, we will call the caregiver listed above. If they do not answer, we will call the emergency contact on file. Please make yourself available by phone/text during while your child(ren) are in our care and let the emergency contact know that it's possible to receive a call from us. Please type your initials in the box below that you have read and agree to this policy. *
Caregiver/Guardian Initial Here
Emergency Contact Name: (other than caregiver listed above)*
Emergency Contact Relationship To Youth*
(example: mother, father, aunt)
Emergency Contact Phone Number*

Area CodePhone Number
Emergency Contact E-mail*
example@example.com
Our programs are open to everyone regardless of ability to pay. If you would like to add a donation to support this and other ongoing programming, you can do so HERE.

We also accept in-kind snack, beverage, supply donations. Thank you for your kind support!

♡
Should be Empty:

TCFH & BOTS Waiver/Release/Intake Form

Information about the person who died

Youth Allergies

Health & Mental Health History

Child(ren) Information

Child(ren) Information

Waivers

Authorized for drop-off / pick-up

Confidentiality

Expectations/Communications