Opportunity Youth Paperwork Opportunity Youth Paperwork Step 1 of 3 33% Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email STATISTICAL INFORMATIONTo qualify for grants and other funding essential to the continued existence of the program, we must supply certain statistical information about the families we serve. Thank you for taking the time to respond to each of the following questions. Your candid answers are very important to us. They will remain anonymous and be kept strictly confidential.Date of Birth* MM slash DD slash YYYY Ethnicity* White Hispanic Black Asian American Indian Primary Language* English Spanish Gender* Female Male Attending School?* Yes No If yes, what school are you attending? Employed?* Yes No If yes, what is the name of your workplace? Please tell us a few things about the person/people in your life who have died:Name of the person who died: First Last SexAgeTheir BirthdateRelationshipDate of DeathCause of DeathName of the person who died (2): First Last SexAgeTheir BirthdateRelationshipDate of DeathCause of DeathName of the person who died (3): First Last SexAgeTheir BirthdateRelationshipDate of DeathCause of DeathEmergency Contact InformationEmergency Contact Name* First Last Your relationship to them:* Emergency Contact Phone Number* AGREEMENT FOR PARTICIPATION IN THE OPPORTUNITY YOUTH PROGRAMSupport Group* I understand the mission of Tu Nidito and the goals of the Young Adult program and agree to be a part of this program.The Opportunity Youth program offers support for grieving teens/young adults between the ages of 16-24. Tu Nidito provides a safe, secure environment in which teens and young adults may share and explore their experiences of loss. Tu Nidito offers no therapy or counseling.Consistency* I understand and agree to these terms.A major value of support groups is consistency. I agree to make attendance a priority. If my attendance becomes inconsistent, I understand that I may be asked to close from group and to return when I am able to make a commitment to consistency. If an absence is unavoidable, I agree to let the Group Coordinator know, 322-9155 or [email protected], as far in advance as possible. Confidentiality* I agree to this confidentiality policy.Confidentiality is based on all participants’ basic right to privacy. It provides the emotional safety necessary for sharing experiences. a) I understand the importance of confidentiality and agree to keep information and experiences shared in group in the strictest of confidence. b) The staff and facilitators of Tu Nidito hold the information that we give about our lives or hear from other participants as strictly confidential, except when bound by law in situations where they have concern about suicide, physical or sexual abuse, or any life threatening behaviors.Disclosure* I have disclosed any special physical, medical, behavioral, emotional, legal issues or needs to ensure the maximum benefit in the Opportunity Youth program. Comments: Substance Abuse* I agree to the Substance Abuse Policy.I understand the importance of safety in a support group. I agree to abstain from the use of alcohol or mind/mood altering substances before group.Grievance Policy* I agree to the Grievance Policy.Tu Nidito clients have an opportunity for a fair hearing for grievances arising from the delivery of services including but not limited to ineligibility determination, service reduction, suspension, termination or quality of service. If you have a grievance, please contact Tu Nidito Executive Director, Liz McCusker at 322-9155. Additionally, you may contact Pima County Outside Agency as we receive partial funding for our services from the county.On Time Policy* I agree to the On Time Policy.As a courtesy to other members of the group and in order to fully participate in the evening’s activities, participants are asked to arrive online to group no later than 1:00 pm. We acknowledge that there are circumstances beyond our control that will occasionally contribute to arriving to group late. RELEASE AND WAIVER OF LIABILITYIMPORTANT: THIS IS A LEGAL DOCUMENT. PLEASE READ CAREFULLY!Waiver and Release* I agree to this policy.I hereby release and forever discharge and hold harmless Tu Nidito and its successors and assigns from any and all liability, claims, demands and causes of action, of whatever kind or nature, either in law or equity, which may hereafter arise from the participation in any program, service, project, activity or event sponsored, managed, arranged, or promoted by, or otherwise affiliated or associated with Tu Nidito. I understand and acknowledge that this Release discharges Tu Nidito from any liability or claim that I may have against Tu Nidito with respect to any bodily or other injury, illness, death, or property damage that may result from our participation. I also understand that Tu Nidito does not assume any responsibility or obligation to provide financial assistance or other assistance, including, but not limited to, medical, health, or disability insurance, in the event of injury, illness, death, or property damage.Participation Consent* I agree to this policy.The undersigned hereby gives permission to receive services from Tu Nidito and participate in any and all activities, including transportation.Release of Liability* I agree to this policy.The undersigned understands that occasionally accidents occur and that participants may sustain serious personal injury as a consequence thereof. Knowing the risks, nevertheless, the undersigned hereby agrees to assume those risks and to hold harmless Tu Nidito, its employees, Board of Directors and volunteers from any and all liability, claims for personal injury and/or property damage, costs, expenses, and damages arising out of or connected in any way with my involvement with Tu Nidito. Further, the undersigned acknowledges that Tu Nidito accepts no responsibility for the loss, damage or theft of personal property.Other* I agree to this policy.I expressly understand and agree that this Release is intended to be as broad and inclusive as permitted by law, and that the Release shall be governed by and interpreted in accordance with the laws of the State of Arizona. I agree that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release.Participant Signature (or Parent/Guardian Signature if under 18):*By signing here, I acknowledge that I have read and understand this Release, and agree to its provisions.