Open House Night at Felius Cat Cafe & Rescue

ADULT 2: Personal Information

Are you attending with another adult (19 or older)? Please register them below.
Adult 2: Full Name*

Adult 2: First NameAdult 2: Last Name
Adult 2: What should we call them if different than above? (preferred name or nickname)
Adult 2: Preferred Name
Adult 2: Phone Number*

A2: Area CodeA2 Phone Number
Adult 2: E-mail*
example@example.com
Adult 2: Birth Date: *

MonthDayYear
ADULT 2: Demographics

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. Your personal information is kept confidential and is not reported alongside the details shared in this section. Thank you for whatever information you are comfortable sharing for this purpose.
Adult 2: Gender*
Adult 2 Gender
Adult 2: Pronouns*
Adult 2 Pronouns
Adult 2: Ethnicity*
Adult 2 Ethnicity
Adult 2: Occupation*
Adult 2 Occupation
Adult 2: Annual household income (if different than adult 1)
(This information is used for record keeping and grant reporting. This will be kept confidential and will only be reported anonymously.)
Are you attending this event with any children?*

YesNo

Child(ren) Information

Please fill out the following for each child 6+ who will be attending the event. 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 1: Full Name*

Child1: First NameChild1: Last Name
What should we call Child 1 if different than above? (preferred name or nickname)
Child 1: Preferred name
Child 1: Birth Date: *

MonthDayYear
Child 1: Current Age:*
Child 1 Current Age
Child 1: School District*
Child 1 School District
Child 1: School*
Child 1 School
Child 1: Grade*
Child 1 Grade
Child 1: Gender*
Child 1 Gender
Child 1: Pronouns*
Child 1 Pronouns
Child 1: Ethnicity*
Child 1 Ethnicity
Is your child(ren) eligible for free or reduced lunch at school?*

YesNoPrefer not to disclose
Are you attending this event with another child?*

YesNo

Child 2 Information

Please fill out the following for each child 6+ 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 2: Full Name*

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

MonthDayYear
Child 2: Current Age:*
Child 2 Current Age
Child 2: School District*
Child 2 School District
Child 2: School*
Child 2 School
Child 2: Grade*
Child 2 Grade
Child 2: Gender*
Child 2 Gender
Child 2: Pronouns*
Child 2 Pronouns
Child 2: Ethnicity*
Child 2 Ethnicity
Are you attending this event with another child?*

YesNo

Child 3 Information

Please fill out the following for each child 6+ 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 3: Full Name*

Child 3: First NameChild 3: Last Name
What should we call Child 3 if different than above? (preferred name or nickname)
Child 3: Preferred name
Child 3: Birth Date: *

MonthDayYear
Child 3: Current Age:*
Child 3 Current Age
Child 3: School District*
Child 3 School District
Child 3: School*
Child 3 School
Child 3: Grade*
Child 3 Grade
Child 3: Gender*
Child 3 Gender
Child 3: Pronouns*
Child 3 Pronouns
Child 3: Ethnicity*
Child 3 Ethnicity
Are you attending this event with another child?*

YesNo

Child 4 Information

Please fill out the following for each child 6+ 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 4: Full Name*

Child 4: First NameChild 4: Last Name
What should we call Child 4 if different than above? (preferred name or nickname)
Child 4: Preferred name
Child 4: Birth Date: *

MonthDayYear
Child 4: Current Age:*
Child 4 Current Age
Child 4: School District*
Child 4 School District
Child 4: School*
Child 4 School
Child 4: Grade*
Child 4 Grade
Child 4: Gender*
Child 4 Gender
Child 4: Pronouns*
Child 4 Pronouns
Child 4: Ethnicity*
Child 4 Ethnicity

Waivers
Artwork, Photographs, and Video Images

I authorize The Collective for Hope 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 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 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, 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, 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 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 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. 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, 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, 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.
Do you agree with the above statements?*
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.
Client/Parent/Guardian/Caregiver Signature (typed)*
Signature

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Today's Date*

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Open House Night at Felius Cat Cafe & Rescue

Who is Felius?

Open House Night at Felius is for youth and adults ages 6 and up.

Technology

ADULT 1: Personal Information

ADULT 1: Demographics

ADULT 2: Personal Information

ADULT 2: Demographics

Child(ren) Information

Child 2 Information

Child 3 Information

Child 4 Information

Waivers

Confidentiality & Mandatory Reporting