A Personal Empowerment Program for Adolescent Latinas.  This group addresses the challenges with assimilating to a dual-cultural life and reinforces a sense of pride and connection with Latina culture.  All sessions are facilitated in a relational, strengths-based, trauma-informed, and culturally competent manner.

 

Sessions will be held via Zoom

Tuesdays and Thursdays

January 19th - February 11th

4:00 - 5:00 pm

Consent and Waiver - I understand that the program requires an 8 week commitment and that all program costs are covered by Los Alamos JJAB. I understand that I may contact the JJAB One Circle facilitator or JJAB One Circle coordinator with questions or comments about the One Circle: Girls group or One Circle: Boys group. I understand that One Circle groups encourage creative and verbal expression and that the group guidelines provide the foundation for circle communication.

For the purpose of effective program facilitation, I authorize the mutual exchange of information regarding my child’s participation in One Circle between the JJAB One Circle Facilitator, JJAB One Circle Coordinator, myself as the parent/guardian of the undersigned child, and if applicable the site school’s counselor or Teen Court coordinator.

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 the JJAB Executive Director (P.O. Box 4716, White Rock, NM 87547). I hereby certify that this request has been made voluntarily.

I release Los Alamos JJAB, 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.

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.

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.