The Clubhouse Membership Application – 18 (If Still in High School) Home / The Clubhouse Membership Application – 18 (If Still in High School) Step 1 of 6 16% Member InformationName* First Name Last Name Address* Street Address City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneMobile Phone*Email* Date of Birth* MM slash DD slash YYYY Gender* Race* Black/African American White Asian or Pacific Islander Hispanic/Latino Multiracial Other *If you selected "other" for race, please specify here: Name of the School You Are Attending* Grade* Would you be interested in help with school work?* Yes No Living Arrangements for Member* Living With Parents/Guardians Foster Care/Shelter Group Home/Residential Substance abuse Facility Homeless Hotel Other* *If you selected "other" for living arrangements, please provide details below: Why are you interested in joining The Clubhouse?*What activities interest you? (select all that apply)* Select All Educational/Tutoring Exercise Recreational Activities Volunteer in Community Social Activities/Dances Sports Theater Employment Skills Healthy Eating/Cooking Money Management Music/Art Family Night Holiday Events Off-Site Field Trips Discussion Groups on Teen Issues Improved Family Interaction Games Cultural Events/Plays/Museums Fitness Computer Relaxing/Place to Hang Out Parent/Guardian InformationName* First Name Last Name Relation to Adolescent* Address* Street Address City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneMobile Phone*Email* Emergency Contact InformationIf my parent/guardian cannot be reached, I give permission to the person named as emergency contact to transport me and authorize my medical treatment. Emergency Contact Name* First Name Last Name Relation to Adolescent* Home PhoneWork PhoneMobile Phone*Member Medical History1. Have you now or have you had at any time in the past:a. A medical or limiting condition such as wearing glasses, contacts, or hearing aids?* Yes No b. Special health requirements?* Yes No c. Require a small group size/more individualized care?* Yes No d. Any other physical, psychiatric or behavioral problem?* Yes No e. e. If you answered yes to any of the above items, please provide detailed information.2. Do you take any type of medication, prescription or over-the-counter drug?* Yes No 3. List all medications you are taking or have taken in the past below:PLEASE NOTE: THE CENTER STAFF WILL NOT ADMINISTER MEDICATION!4. Do you have allergies?* Yes No a. If yes, please list all allergies below:b. Do you have allergies that may require medical care?* Yes No c. Does your emergency care require medication administration?* Yes No IF YES: I will complete an “Allergy and Medical Emergency Care Plan” and will provide necessary medications and medication administration forms during the intake process. The Clubhouse Code of Honor 1. We will encourage and lift up other members.2. We will promote tolerance, acceptance and sensitivity to diverse pathways of recovery and diverse cultures. 3. We will be respectful to staff members of The Clubhouse.4. We will walk, not run in The Clubhouse.5. We will refrain from the use of profanity.6. We will be free of any mind-altering chemicals during participation in the program. 7. We will maintain strict confidentiality regarding whom and what we see and hear while participating in The Clubhouse. We will expect the same from others regarding our own confidentiality. 8. We will be on time for meetings and activities.9. When in public, we will stay with staff unless direct permission was given to do otherwise (e.g., to use the restrooms).10. When in public, please use kind language and behavior.11. When in public, we will ensure safety by not participating in horseplay.12. Please let staff know if you need to use the restrooms, we prefer the restroom to be used by one member at a time.13. We will use appropriate websites on the computers.14. We will show respect by not taking supplies from The Clubhouse.15. We will let staff know where we are going if we leave The Clubhouse for safety reasons. (e.g., to use the restroom or when leaving the facility) ** The Rules of Conduct will be clearly posted at the facility and may be subject to review and approval by the Office of Mental Health (OMH)/Core Service Agency (CSA).I have read and agree to the above statements.* Yes Grievance ProcedureThe Grievance Procedure for The Clubhouse will be posted on-site and outlined in the handbook that participants will be given upon acceptance into the program. Participants will be encouraged to ask questions about the policy at any time. A review of formal complaints will be conducted monthly by the director of the Adolescent Clubhouse to determine trends, areas needing performance improvement and actions to be taken. An administrative record of all grievances will be maintained. The participant may report a grievance through Ashley’s website or through written means. All grievances will be directed to the director of the Adolescent Clubhouse who may ask the participant to participate in a problem-solving session with The Clubhouse peer. After the peer has attempted to resolve the issue and the participant is still not satisfied, the grievance will be escalated to the vice president of outpatient services and/or vice president of clinical services of Ashley. The decision from the vice president of outpatient services and/or vice president of clinical services will be final. If Ashley fails to respond as provided in its appeal procedure, or the consumer is dissatisfied with the provider’s response, the consumer may file an appeal with the OMH/CSA.The steps in the appeal process to the OMH/CSA include the following:1. Consumers may file an appeal to the OMH/CSA within 14 days (excluding weekends and holidays) of receipt of the provider’s decision on their grievance. (The OMH/CSA will accept appeals outside of this time frame for good cause.)2. The appeal may be submitted in writing or verbally and include a discussion of the grievance and copy of the decisions (if possible) of the provider.3. The Executive Director or Designee will contact the individuals involved. There will be a review of the information submitted by the grievant and others.4. The OMH/CSA will issue a verbal/written decision to the grievant within 5 days (excluding weekends/holidays).5. If the grievant is dissatisfied with the decision, an appeal may be filed with the president of the OMH/CSA’s Board of Directors. The president will establish a committee to review the merits of the appeal and render a decision in 5 days (excluding weekends/holidays).To file an appeal to the OMH/ CSA, please send the information to the address below:Executive DirectorOffice on Mental Health Core Service Agency of Harford County, Inc. 2231 Conowingo Road, Suite A Bel Air, MD 21015To file an appeal to the OMH/CSA’s Board of Directors pleased send the information to the address below:President of the Board of DirectorsOffice on Mental Health Core Service Agency of Harford County, Inc. 2231 Conowingo Road, Suite ABel Air, MD 21015Telephone Numbers: Monday through Friday 8:30AM – 4:30PM Main #: (410) 803-8726 Fax #: (410) 803-8732 I have read and agree to the above statements.* Yes Transportation Release Consent FormAt times, it may become necessary to use Ashley vehicles to transport The Clubhouse members to and from activities or for an emergency. When this occurs, Ashley Inc. requires you to acknowledge and sign this Transportation Release Consent Form.By signing this form, I hereby release Ashley Inc., as well as its directors, administrators, employees or other agents from all liability or damages for any and all injuries arising from the negligence of any of the above while traveling to any clubhouse activity via Ashley vehicle transportation.Member Signature*Standard Waivers and Release Authorization for ParticipationI am a legally competent adult. I understand that even when every reasonable precaution is taken, incidents and accidents may occur. Therefore, in exchange for The Clubhouse allowing me to participate, I voluntarily and intentionally hold harmless and release Ashley Inc., its employees, volunteers, members and guest from any and all liability for loss, damage, injury or death, including any claims based on ordinary negligence, action or inaction connected to my participation. I also agree to indemnify Ashley Inc. for claims made by or for myself or claims arising from any relationship with myself or my estate. I have read this form and agree to participate in all activities provided by The Clubhouse. Member Signature*Authorization for Emergency Medical TreatmentIf I should become ill or injured during The Clubhouse activities, I understand that The Clubhouse will 1) contact my parent/guardian immediately 2) contact the person(s) I have designated in case my parent/guardian cannot be reached. Should The Clubhouse be unable to reach my parent/guardian or the person(s) designated, The Clubhouse, is authorized to contact my physician or arrange for immediate medical treatment to ensure my health and safety, including the administration of medications or injections provided by me for such purpose. I accept responsibility for payment for medical services rendered. Member Signature*Photo ReleaseAshley Inc. has my permission to use photographs, videos and testimonials of and from myself in The Clubhouse promotional materials.Member Signature* Information and ConsentI am aware that The Clubhouse offers free afterschool activities as well as snacks and drinks. The hours of operation are 2:00 pm to 8:00 pm Monday through Friday and Saturday from 9:00 am to 12:00 pm. My signature below indicates that I have read all consents and guidelines in order to attend the center and participate in all scheduled activities. I am aware that I am responsible for all of my transportation to and from the center. I acknowledge that once I sign out, the center staff is no longer responsible for members or their transportation. Member Signature*I have read, signed and understand the information contained in each of the above waivers and/or releases.Member Signature*Date* MM slash DD slash YYYY Would you like to receive email communication from us to provide you with informative materials and events?* Yes No How did you learn about The Clubhouse?* Flyer in the Mail Newspaper Radio Social Media Internet Search Friends/Family Physician/Therapist Other CAPTCHA Δ
