Bereavement 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*
Email*

Family Members:

Click the plus sign to the right of this entry to add additional family members.

First Name	Last Name	Relationship

Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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
BLOG SUBSCRIPTION*
We consent to receiving email notifications for new blog postings on Tu Nidito's website (www.tunidito.org/blog). When you select "Yes," you will receive a separate follow up email to confirm your free subscription. We encourage you to read the blog from time-to-time to stay up to date on nest happenings and programs, and to have access to extra resources.
- 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.

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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.
Acknowledgement of Tu Nidito Covid-19 Guidance
- I have read Tu Nidito's Covid-19 Guidance.
Participation in Tu Nidito’s Support Groups
By signing below, I agree to the following:*
- I understand the importance of consistency in group attendance. I agree to make attendance a priority. If attendance becomes inconsistent, I understand that we will be asked to close from group and can return when able to consistently attend.
- When my child(ren) have completed our time with Tu Nidito I will: inform my Group Coordinator, announce at group our intention to close, attend at least one more session to say goodbye.
- I understand that Tu Nidito’s focus is providing group support for children and when my child(ren) close from group, adult family members will also close and may be guided to another community support group for adults if desired.
- I understand the importance of confidentiality and agree to keep information and experiences shared in group in the strictness of confidence.
- I understand that Tu Nidito staff and volunteers will not discuss the specifics of my child(ren)’s work with me unless there is concern that my child(ren) may harm themselves or others or are being harmed. I know that I can discuss my child(ren)’s progress with the Group Coordinator either after group or in a phone conversation.
- I understand the staff and volunteers hold all information from participants as confidential except when bound by law in situations where they have concern about suicide, physical or sexual abuse, or any life threatening behaviors.
- I understand that if my child may have an infectious disease I will not bring them to group until I am certain that the contagious stage has passed.
- I agree to abstain from the use of alcohol or mind/mood altering substances before group.
- I understand that volunteers are not available to us outside of support group. If I do need help, I understand that I can call the staff at Tu Nidito.
- We encourage families to attend group together, however if someone other than the custodial caregiver will be dropping off or picking up the child(ren), I understand that I must contact the Group Coordinator prior to the group.
- I understand that I may be asked to complete periodic assessment forms on my child(ren) to ensure the effectiveness of the program and participants progress.
- I understand that if I have a grievance I am welcome to call 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.

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First name	Attended Funeral/Service	Present @ time of death	Other losses	Medications/Allergies/Medical/Mental Health information we should know

Contact Us

Step 1 of 3

CONSENT AGREEMENT AUTHORIZATION AND RELEASE

COVID-19 Guidance, Subject to Change

Participation in Tu Nidito’s Support Groups

Statistical Information

OUR LINKS

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

Ethnicity	Primary Launguage