Families 1st Partnership
421 S. Dewey Street
North Platte, NE 69101
I, _____________________________________, authorize the release of my information to Families 1st Partnership Community Response Agency and their affiliated partner agencies & Coaches.
The below list is not all inclusive. Based on client needs, Families 1st Partnership and its agents/coaches may determine that information may need to be released to other organizations for the purpose of completing tasks or activities that the client may have requested or trigged with their application for assistance.
West Central Nebraska Joint Housing Authority, Region II, Public or Private Schools, Probation/Corrections, Salvation Army, Department of Health and Human Services, EQWS, Landlord (required for rental assistance), Vocational Rehab, Goodwill Industries, Nebraska Department of Labor, Utilities, Faith Based Organizations, MPCC, Community Action, The Connection, Central Plains, Independence Rising, Great Plains Health, Region II and any other organization as directed by Families 1 st Partnership.
I, _________________________________________, do hereby affirm and acknowledge that I am responsible to be aware of the risks associated with accessing available programs/trainings/financial support provided by Families 1St Partnership, including damage to property belonging to me or to others, injury, illness, or other unforeseen circumstances to myself or others, whether caused by me or by others or by conditions/circumstances within or outside of my control or the control of others. I understand an exhaustive description of potential hazards and risks associated with such activity(ies) is not possible and that unknown or unanticipated hazards or risks may result in injury, illness, or death. If equipment is involved in such activity (ies), I agree to inspect all such equipment before use, ask questions if I do not fully understand how to us and/or operate the equipment, accept all equipment “as is”, and to return all equipment before use that is believed to be damaged or defective.
In consideration of my being provided the opportunity to participate in such activity (ies), I fully and completely assume all hazards and risks associated with such activity (ies) and by signing this Waiver and Risk Agreement, do hereby forever waive any responsibility or liability on the part of and completely release Families 1st Partnership, and its officers, directors, members, employees and agents from any and all claims or liability or damage, known and unknown, now and hereafter existing in connection with my participation in any form whatsoever in such activity (ies).
I have read the foregoing Waiver and Risk Agreement. I fully understand the terms and that I may have given up legal rights by signing this document. I sign it freely and voluntarily with the intent to be bound to the terms of this document. My agreement is binding on me and my heirs, estate, and any other parties who may be able to assert a claim by or through me.
I, ______________________________________________, authorize and understand that I have been made aware of Families 1st Partnerships HIPAA privacy practices. As Families 1st partnership operates in the state of Nebraska, the Department of Health & Human Services (DHHS) monitors HIPAA disclosure for the purpose of rendering & engaging in services. My signature on this form grants access and disclosure to my own personal or children’s PHI (Protected Health Information) for the purpose of completing or rendering services via Families 1st Partnership.
Families 1st Partnership, and its officers, directors, members, employees and agents will be allowed to access my or my children’s PHI at any time after signature of this Release for the purpose of completing my request/application & services based on the application that I submit.
My HIPAA authorization can be revoked at anytime by notifying Families 1st Partnership in writing at the above listed address. If I revoke my authorization before services have concluded, Families 1st Partnership may terminate my services due to lack of information or ability to disclose PHI to its officers, directors, members, employees, and agents.
By signing below, I understand that I must complete the Community Response Exit Survey. If I do not complete the survey, I may not be able to receive any further assistance from Families 1st Partnership funding. The Community Response Exit Survey will be provided to you at the anticipated last coaching visit and/or within 30‐90 days of enrollment into Community Response.
I have read the foregoing Waiver and Risk Agreement, Client Release of Information & HIPAA Disclosure & Release. I fully understand the terms and that I may have given up legal rights by signing this document. I sign it freely and voluntarily with the intent to be bound to the terms of this document. My agreement is binding on me and my heirs, estate, and any other parties who may be able to assert a claim by or through me.
|Signature of adult participant||Name of adult participant (printed)||Date|
FOR PARTICIPANTS UNDER THE AGE OF 19: I, as parent or Legal Guardian for the minor child/children named below, do hereby sign this document for and on behalf of the minor child, and consent and agree to such child’s participation in the activity (ies) made available through Families 1st Partnership, and on behalf of the minor child and such child’s parents or Legal Guardians join in and agree to be bound to this Risk and Waiver Agreement.
Signature of adult participant
Name of adult participant (printed)
Signer’s relationship to Minor Child/Children: