The Clubhouse Membership Application – Minors

If I cannot be reached in an emergency, I hereby give permission to the person named as emergency contact to transport my adolescent and authorize their medical treatment.

1. Has your adolescent now or had at any time in the past

PLEASE NOTE: THE CENTER STAFF WILL NOT ADMINISTER MEDICATION!

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.

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 to 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 horse play.

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).

The 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 Director

Office on Mental Health

Core Service Agency of Harford County, Inc.

2231 Conowingo Road, Suite A

Bel Air, MD 21015

To file an appeal to the OMH/CSA’s Board of Directors pleased send the information to the address below:

President of the Board of Directors

Office on Mental Health

Core Service Agency of Harford County, Inc.

2231 Conowingo Road, Suite A

Bel Air, MD 21015

Telephone Numbers:

Monday through Friday 8:30AM – 4:30PM

Main #: (410) 803-8726

Fax #: (410) 803-8732

The Clubhouse members will have opportunities to watch movies. The following rating types are what we will show, and your signature provides permission for your adolescent to watch these rated films.

• G rated movies

• PG rated movies

• PG-13 movies

At times it becomes 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 as the parents/guardians 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.

I am a legally competent adult who is the parent/guardian of the named participant. I give my permission for my child to participate in The Clubhouse. I understand that even when every reasonable precaution is taken, incidents and accidents may occur. Therefore, in exchange for The Clubhouse allowing my adolescent to participate, I voluntarily and intentionally hold harmless and release Ashley Inc., its employees, volunteers, members and guests from any and all liability for loss, damage, injury or death, including any claims based on ordinary negligence, action or inaction connected to my adolescent’s participation. I also agree to indemnify Ashley Inc. for claims made by or for the participant or claims arising from any relationship with the participant or the participant’s estate. I have read this form and grant permission for my adolescent to participate in all activities provided by The Clubhouse.

If my adolescent should become ill or injured during The Clubhouse activities, I understand that The Clubhouse will 1) contact me immediately 2) contact the person(s) I have designated in case I cannot be reached. Should The Clubhouse be unable to reach me or the person(s) designated, The Clubhouse is authorized to contact my physician or arrange for immediate medical treatment to ensure the health and safety of my adolescent, including the administration of medications or injections provided by me for such purpose. I accept responsibility for payment for medical services rendered.

Ashley Inc. has my permission to use photographs, videos and testimonials of and from my child in The Clubhouse promotional materials.

I am aware that my adolescent will visit The Clubhouse. I am aware that the center offers free after-school activities as well as snacks and drinks. The hours of operation are 2:00 pm to 8:00 pm Monday and Wednesday through Friday when school is in session. During the summer we are open from 10:00am to 4:00 pm. I am also aware that tours of the center are available and that I can tour the center at any time during those hours, with or without the adolescent member. My signature below indicates that I have granted permission for my adolescent to attend the center and participate in all scheduled activities. I am aware that I am responsible for all of their transportation to and from the center. I am aware that I will need to give permission for any off-site activities that the center offers and may agree to sign a separate permission form for those activities.

I acknowledge that once a adolescent member signs out, the center staff is no longer responsible for the adolescent members or their transportation.

I have read, signed and understand the information contained in each of the above waivers and/or releases.