One Circle Registration Form Jiu Jitsu Spring 2021

One Circle Registration Form
Los Alamos JJAB has partnered with LAB Jiu Jitsu to bring middle school and elementary school (5th and 6th grade) youth a unique learning opportunity. The One Circle programs will focus on positive communication skills, positive self-image, respect for yourself, others, and the community, and explore what it means to be a friend.

All sessions will be held on

Wednesdays, January 20th - March 10th

4:00 - 5:15 pm

Sessions will be held via Zoom video conferencing. All sessions will start out with a 30 minute combined Jiu-Jitsu group (all youth). Following that participants will break out into separate sessions, with a One Circle facilitator, for elementary girls, elementary boys, middle school girls, and middle school boys.
Please indicate which One Circle group the youth will participate in:
*

5th and 6th Grade Elementary Girls 5th and 6th Grade Elementary Boys Middle School Girls Middle School Boys
Child's Name: *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Age *
School *
Grade *
Gender *
Ethnicity *
If American Indian/Native Alaskan, please indicate tribe:
Referred to Program By *
Parent/Guardian Contact Information (supplies and materials for the session may be delivered to this address) *

Name

Street Address

City State / Province

Postal / Zip Code Country
Parent/Guardian E-mail *
Parent/Guardian Phone Number *
Additional Contact Information

Name

Relationship to Child

Phone Email
Consent and Waiver - I understand that the program requires an 8 session commitment and that all program costs are covered by the Los Alamos JJAB. I understand that I may contact the JJAB facilitator with questions or comments. I understand that the program encourages creative and verbal expression and that the circle guidelines provide the foundation for circle communication. I understand that this program is completely voluntary and that LA LAB Jiu Jitsu and JJAB are partnering to bring this unique experience. JJAB and LA LAB Jiu Jitsu are separate entities and hold separate responsibility.

For the purpose of effective program facilitation, I authorize the mutual exchange of information regarding my child’s participation in the One Circle between the One Circle facilitator, and LA LAB Jiu Jitsu, Professor Romero, and myself as the parent/guardian of the undersigned child.

All information will remain confidential per the JJAB Privacy Practices, unless I have authorized its exchange, except in the following circumstances: danger of one acting on suicidal or homicidal thoughts, danger of injury to oneself or others, suspected child or vulnerable adult abuse or neglect, or court subpoena. I have received the Notice of JJAB Privacy Practices. This authorization may be revoked at any time by submitting a written request to JJAB Resource Specialist (P.O. Box 4716, White Rock, NM 87547). I hereby certify that this request has been made voluntarily.

I release the Los Alamos Juvenile Justice Advisory Board, its contractors, and its employees, from liability for any claims by me or any third party in connection with the participation of the undersigned minor child. I hereby give my consent for the undersigned child below to participate in the above program.
Signature Date *

Month Day Year
Parent Signature *

Clear
Questions can be directed to Danielle Sutherland, One Circle Coordinator at (505) 709-5121 or danielles@losalamosjjab.com.

Standard Photo and Video Release Form
for Minor Children-One Circle: Girls & One Circle: Boys

I hereby authorize Los Alamos JJAB to publish the photographs taken of myself and/or the undersigned minor children, for use in Los Alamos JJAB's printed publications, website, and social media accounts for the purpose of promoting their programs.

I attest that I am the parent or legal guardian of the children listed below and that I have the authority to authorize Los Alamos JJAB to use their photographs.

I acknowledge that since participation in publications, websites and social media accounts produced by the Los Alamos JJAB is voluntary, neither the minor children nor I will receive financial compensation.

I further agree that participation in any publication, website, or social media produced by JJAB confers no rights of ownership whatsoever. I release the Los Alamos JJAB, its contractors and its employees from liability for any claims by me or any third party in connection with my participation or the participation of the undersigned minor children.
Child's Name:

First Name Middle Name Last Name
Childs' Date of Birth

Month Day Year
Date
Parent's Name

First Name Last Name
Signature Date

Month Day Year
Parent Signature

Clear

Los Alamos Juvenile Justice Advisory Board (JJAB)
Privacy Policy
Effective Date 03/01/2017

This notice describes how personal/private information (PPI) information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights
When it comes to your personal information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your Case Management file
• You can ask to see or get a copy of your Case Management file and other personal information we have about you.
• We will provide a copy or a summary of your personal information, usually within 30 days of your written request.

Ask us to correct your Case Management file
• You can ask us to correct personal information about you that you think is incorrect or incomplete.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone). We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
• All information will remain confidential except in the following circumstances: danger of one acting on suicidal or homicidal thoughts, suspected child or vulnerable adult abuse or neglect, or court subpoena.
• You can ask us not to use or share certain personal information for our referral services or our operations.
• JJAB shares only de-identified information with organizations/grants that provide funding for our programs. This can include a birth month and/or year, ethnicity, and/or zip code/city of residence.

Choose someone to act for you
• If you have given someone power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your service referral.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated
• If you feel your rights have been violated, you can make a complaint by contacting us directly.
• You may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/.
• We will not retaliate against you for filing a complaint.

Your Choices
You have a right and a choice regarding sharing any of your information. For certain information, you can tell us your choices about what we may share. If you have a clear preference for how we share your information in the situations described below, talk to us.

Sharing Information
• For JJAB to share any information with any person or organization, except in the circumstances of danger to oneself or others as defined above, you must sign a Release of Information.
• A Release of Information is a document signed by you, where you explicitly state with whom we can share information about you. This may allow us to share information with your family, close friends, your school or others involved in your care.

Our Uses and Disclosures
How do we typically use or share your personal information? Referral Services

We can use your personal information and share it with other professionals for referral purposes.
Example: A Resource Specialist may refer you to a doctor if you identify a need for services.

Run our organization
We can use and share your personal information to improve your care and contact you when necessary.
• The organization is the owner of all official JJAB documents which are kept confidential as directed by privacy rules.
Obtain funding for the programs used to aid and support you
JJAB shares de-identified information with organizations/grantors that provide funding for our programs.
• This information can include a birth month and/or year, gender, ethnicity, tribal affiliation and/or zip code/city of residence.

Safety issues
We can share personal information about you for certain situations such as:
• Reporting suspected abuse, neglect, or domestic violence.
• Preventing or reducing a serious threat to anyone’s health or safety.

Do research or for program development
We can use or share de-identified information for program development.
Example: The JJAB coordinator may report compiled data such as - 24 Youth expressed a need for walk-in mental health services.

Comply with the law

We will share information about you if state or federal laws requires this. It may include, but not be limited to, sharing information with the Department of Health and Human Services in order for the agency to verify that we are compliant with federal privacy law.

• For law enforcement purposes or with a law enforcement official
• With oversight agencies for activities authorized by law

Respond to lawsuits and legal actions
We can share information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities
• We are required by law to maintain the privacy and security of your protected personal information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of the Privacy Policy. We will not use or share your information other than as described here unless we inform you in writing. If you give us permission to share your information, this permission may be revoked at any time. This revocation must be put in writing and provided to JJAB.
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