The Clubhouse Membership Application – Minors Home / The Clubhouse Membership Application – Minors "*" indicates required fields Step 1 of 6 16% Adolescent/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* White Black/African American Hawaiian/Pacific Islander Asian American Indian/Alaska Native More Than One Race Other Ethnicity* Hispanic/Latino Not Hispanic/Latino *If you selected "other" for race, please specify here: Name of the School Your Adolescent Is Attending* Grade* Would you be interested in Ashley staff helping with school work?* Yes No Living Arrangements for Your Adolescent* 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 having your adolescent join The Clubhouse?*What activities interest them? (select all that apply)* 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 Select All 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* Do we have permission to add you to our mailing list (we do not sell our lists)?* Yes No Emergency Contact InformationIf 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.Emergency Contact Name* First Name Last Name Relation to Adolescent* Home PhoneWork PhoneMobile Phone*Adolescent Medical History1. Has your adolescent now or had at any time in the pasta. 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. If you answered yes to any of the above items, please provide detailed information below:2. Does your adolescent take any type of medication, prescription or over-the-counter drug?* Yes No 3. List all medications your adolescent is taking or has taken in the past below:PLEASE NOTE: THE CENTER STAFF WILL NOT ADMINISTER MEDICATION!4. Does your adolescent have allergies?* Yes No a. If yes, please list all allergies below:b. Does your adolesent have allergies that may require medical care?* Yes No c. Does your adolescent’s 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 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).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 HealthCore Service Agency of Harford County, Inc.2231 Conowingo Road, Suite ABel 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 HealthCore 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) 803-8732I have read and agree to the above statements.* Yes Movie Viewing DisclaimerThe 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 moviesParent/Guardian Signature*Transportation Release Consent FormAt 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.Parent/Guardian Signature*Standard Waivers and Release Authorization for ParticipationI 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. Parent/Guardian Signature*Authorization for Emergency Medical TreatmentIf 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. Parent/Guardian Signature*Photo ReleaseAshley Inc. has my permission to use photographs, videos and testimonials of and from my child in The Clubhouse promotional materials.Parent/Guardian Signature Parental/Guardian Information and ConsentI 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. Parent/Guardian Signature*I have read, signed and understand the information contained in each of the above waivers and/or releases.Parent/Guardian Signature*Date* MM slash DD slash YYYY 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 Seach Friends/Family Physician/Therapist School Community Provider Other *If you selected "other", please specify here:* CAPTCHA Δ
