Serious Medical Condition - Child Intake Form * Tu Nidito

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CONSENT AGREEMENT AUTHORIZATION AND RELEASE
This Consent Agreement, Authorization and Release must be read and signed in order for your child and family to receive services through Tu Nidito.
Family Last Name(s):*
Phone*
Name of Child Diagnosed
First Last

Family Members:

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First Name	Last Name	Relationship to Diagnosed Child

Address
Street Address Address Line 2 City State ZIP Code
WAIVER AND RELEASE*
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.
RELEASE OF LIABILITY*
The undersigned parent/guardian 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.
ART/MEDIA RELEASE*
To communicate Tu Nidito’s mission, we sometimes want to use quotations, photos, video, stories or artwork from the group participants for display boards, brochures, grant applications, newsletters or trainings. The last name of the participant is never spoken or printed. Participation is voluntary.
- We give our permission to the above uses of artwork, quotations, and stories.
- We give our permission to the above uses of photos or videos.
- We do NOT give our permission to any uses of photos, videos, artwork, quotations, and stories.
THERAPY DOG RELEASE*
We consent for the above named family members to interact with a pet therapy dog at Tu Nidito. If there is an allergy or fear of dogs or if there is a cultural barrier for interacting with dogs or if for any other reason you would prefer not to have interaction with a therapy dog, please check no.
- Yes
- No
Signature*
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. By signing below, I acknowledge that I have read and understand this Release, and agree to its provisions. I further represent that I am an authorized signor for the family and family members listed above.

Tu Nidito Covid-19 Guidance, Subject to Change
Individuals identified as Close Contacts to a COVID positive person are divided into two groups:
1. Those who have been boosted OR who have completed the primary series of Pfizer or Moderna vaccine within the past six months OR who have completed the primary series of J&J vaccine within the past 2 months.
2. Those who have completed the primary series of the Pfizer or Moderna vaccine more than 6 months ago and are not boosted OR who have completed the primary series of J&J over 2 months ago and are not boosted OR who are unvaccinated.
Exposure to COVID-19:
Fully vaccinated individuals, with a booster, who are identified as a Close Contact to a COVID positive person:
Do not need to quarantine, but you will be required to wear a mask while at Tu Nidito and should test on day 5 from initial contact.
Individuals identified as a Close Contact to a COVID positive person who are unvaccinated OR individuals who are beyond 6 months from completing the primary series of Pfizer or Moderna OR individuals who are beyond 2 months from completing the primary series of J&J:
Must quarantine for 5 days, wear a mask while at Tu Nidito and should test on day 5 from initial contact.
Testing Positive for COVID-19:
All Individuals: Isolate for 5 days; then:
No symptoms: Return to normal activities and wear a mask at Tu Nidito.
Symptoms after 5 days: Stay home until you have no fever for 24 hours; wear a mask at Tu Nidito.
No Symptoms after 5 days: Return to normal activities and wear a mask at Tu Nidito.
It is Tu Nidito's policy that all individuals on Tu Nidito property wear a mask at all times.
- I have read Tu Nidito's Covid-19 Guidance
Tu Nidito Participation Agreement
I consent for my child(ren) and family to be enrolled in Tu Nidito’s one-on-one program:*
By electing these services, I acknowledge and consent to the following:
- The purpose of Tu Nidito services is to provide emotional and social support to my family as we navigate our child’s serious medical condition through play, art, games, structured discussions, and other activities. Tu Nidito services are individualized and designed to benefit all members of my family.
- My family has a right to participate in the development of a plan of care which reflects the psychosocial needs of my family and which will be reviewed twice yearly.
- Tu Nidito services include professional staff as well as trained volunteers.
- In order to receive the full benefit of Tu Nidito services, it is important for me to make my family’s needs and concerns known to my assigned Support Specialist.
- Tu Nidito will protect the confidentiality of all members of my family, except in the case where there is a concern for danger, harm, or risk to self or others.
- Records are released only in accordance with applicable federal or state law that authorizes release or disclosure or with written authorization from my child’s legal representative. There are no apparent risks to my children and family by receiving care from Tu Nidito.
- There is no charge for services received by Tu Nidito.
- In order to better serve my family, it is important for Tu Nidito staff to communicate with my medical team, including physicians, case managers/social workers, nurses, home health agencies, school personnel, and DCS case managers when DCS is involved. I authorize any such entity to disclose all or any part of my child’s records to Tu Nidito and authorize Tu Nidito to share pertinent information with these sources.
- I can discontinue any and all aspects of Tu Nidito services at my discretion.
- My family has a right to services and care regardless of race, religion, gender, or national origin.
- I have been given ample opportunity to ask any and all questions I have concerning Tu Nidito services.
- 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.

Contact Us

Step 1 of 3

CONSENT AGREEMENT AUTHORIZATION AND RELEASE

Tu Nidito Covid-19 Guidance, Subject to Change

Tu Nidito Participation Agreement

Statistical Information

OUR LINKS

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Tu Nidito offices will close december 22nd and will re-open january 2nd

Ethnicity	Primary Launguage

First name	Relationship to diagnosed child	Medications/Allergies/Medical/Mental Health information