In Full Bloom Registration Step 1 of 3 33% Name* First Last Preferred Name Date* MM slash DD slash YYYY Age*Date of Birth* MM slash DD slash YYYY Gender* Female Male Race* Ethnicity* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Phone NumberEmail* Number of Children* 0 to 5 years old 6 to 10 years old 11 to 15 years old 16+ years old Number of Children (0 to 5 years old)*Please enter a number greater than or equal to 1.Number of Children (6 to 10 years old)*Please enter a number greater than or equal to 1.Number of Children (11 to 15 years old)*Please enter a number greater than or equal to 1.Number of Children (16+ years old)*Please enter a number greater than or equal to 1.Do you have an occupation?* Yes No Occupation* Place of Employment* Do you have allergies?* Yes No Allergies* Emergency ContactName of Emergency Contact* First Last Relationship* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Phone NumberEmail* Would you be interested in more support from your child's father?* Yes No Unsure What times are best for you to participate in our program? (check all that apply)* Weekday Mornings Weekday Afternoons Weekday Evenings Saturday Mornings Saturday Afternoons What long term or short term goal(s) would you like to achieve?*Which activity would you be interested in participating in? (Choose all that apply)* Parent/Child Relationship building Parenting Classes An individual mentor who would assist you in achieving your goals Financial Planning Classes (tax preparation, debt consolidation, budgeting, etc.) Job Skills Classes (resume writing, interview skills, etc.) Stress Management Classes Group Therapy Individual Counseling Other. Other* Consent* The information in this registration form is accurate and complete to the best of my knowledge. I want to be involved with the In Full Bloom program. I understand the information in this application will remain confidential and be used only by In Full Bloom facilitators. I understand this is a voluntary program and that In Full Bloom events must be a top priority for me during the program.Signature*Date* MM slash DD slash YYYY ZOOM VIDEO CONSENT FORMI consent to Zoom video meetings with Bloom Upstate. Zoom meetings are provided via internet, which can include groups, mentorship, and family education. I also understand that Zoom video involves the communication of my information, orally and/or visually. Client Rights, Risks and Responsibilities: The client needs to be a resident of South Carolina, I the client have the right to withhold or withdraw consent at any time without affecting my right to future care treatment. The laws that protect the confidentiality of my information also applies Zoom video meetings. I understand that the information disclosed by me during my meeting is generally confidential. However, there are mandatory and permissive exceptions to confidentiality, which are described in the professional disclosure statement and consent to treat form, which is located at the end of the professional disclosure statement. I understand that there are risk from Zoom video meetings, including but not limited to, the possibility, despite best efforts to ensure high encryption and secure technology on the part of my clinician, that: the transmission could be disrupted or distorted by technical failures and could be interrupted by authorized persons; and services could be disrupted or distorted due to unforeseen technical problems. I understand that Zoom video meetings and care may not be as complete as face to face services. I understand that I may benefit from Zoom video meetings, but the results cannot be guaranteed or assured and that no promises have been made to me as to the results of the outcome of treatment provided by the mentor. I understand mentorship is a collaborative effort and that the results of my progress depends on my willingness to engage in treatment to meet my treatment goals. I accept that Zoom video meetings do not provide emergency services. I understand that mentorship does not include mental health services. If I am experiencing an emergency situation or having suicidal or homicidal thoughts, I will contact 911, go to your local emergency room, or call the South Carolina Suicide Hotline 864-582-1100, Teen Line, 864-467-8336, or contact the National Suicide Hotline at 1-800-273-8255 (Talk). I have that I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my Zoom video sessions, (2) arranging a location with privacy that is free from distractions or intrusions for my Zoom video session. To maintain confidentiality, I will not share my Zoom video meeting appointment link with anyone unauthorized to attend the appointment. I have read, understand and agree to the information providedSignature*Client or Guardian signatureDate* MM slash DD slash YYYY Signature*Provider SignatureDate* MM slash DD slash YYYY In Full Bloom Professional Disclosure StatementBloom Upstate is a non-profit organization who mission is to support and mentor at-risk-girls and their families in Spartanburg County who are without an active father. The vision of the organization is creating an atmosphere where all girls feel valued and encouraged by adults who actively invest in them. Bloom Upstate is a non-profit organization that is supported and funded by grants and donations. Bloom Upstate is a non-profit organization that provides mentorship, family services, peer group, tutoring, and other support services. Below are the following programs offered by Bloom Upstate: Mentorship Bloom Upstate matches single mothers with professional mentors to help support them in achieving their goals. The mentorship is design to build self-esteem, develop positive peer relationships, develop life and vocational skills, and connect with resources in the community. Parenting Classes Bloom Upstate partners with other local organizations and professional instructors to provide parenting resources. Bloom Upstate adheres to the Triple P parenting philosophy. Information and resources relating to Triple P can be found at https://hopecfc.org/triplep/. Parent/Child Bonding Activities Bloom Upstate recognizes the importance of strong parental bonds in both childhood development as well as alleviating parental stress. Bloom Upstate will provide evidence based resources on strengthening parental bonds. Bloom Upstate will also host periodic events with the goal of strengthening the parent/child bond. Therapy and Family Services Bloom Upstate partners with other community professionals to provide therapy and family services at this time. Bloom Upstate will make a referral to a licensed practitioner of therapy and family services.Bloom Upstate is an organization that complies with federal, state and local laws. The following topics below explain in event abuse and neglect, confidentiality, duty to warn and protect where Bloom Upstate shall report to the appropriate authorities. Privacy and Confidentiality Content of all peer group sessions are confidential. Both verbal information and written records (electronic or verbal) cannot be shared with another party without your written consent, or written consent of your legal guardian. If you opt to use electronic communication such as email, faxing and mobile phone text messaging to transmit information relating to schedule of a group session or other activities provided by the organization, electronic communication is not generally secure. The confidentiality form will have an option what method of contact you would like to use. If a court of law or other legally authorized entity orders me to disclose confidential or privilege information without your consent. I will protect the confidentiality during legal proceedings to the extent permitted by law. Additionally, I would request that the court withdraw the order or limit the order as narrowly as possible or maintain the records under sealed, unavailable for public inspection. Duty to Warn and Protect I am a mandated reporter by law. If you disclose that you have intentions to harm another person, I am required by law to warn the intended victim and report this information to legal authorities. If you disclose or imply to me a plan for suicide, I am required to notify legal authorities and make reasonable attempts to notify your family and any person (s) listed on your emergency contact information. Abuse and Neglect If you disclose or suggest that you have been abuse, you are abusing a child, abusing a vulnerable adult or a child or vulnerable adult is in danger of abuse, I am required to report this information social services and/or legal authorities. In the event there is admission to prenatal exposure to controlled substances that are potentially harmful, or children that are expose to controlled substances or in the present of domestic violence in the home, I am required to report to social services and/or legal authorities. Informed Consent: By your signature below you indicating the following: You voluntarily agree to receive and participate in Bloom Upstate’s mentorship services and that you give consent for the organization to provide such services and when necessary make a referral to the appropriate facilities to address your needs. You understand and agree that you will participate in the planning and activities the organization provides and you can stop services at any time. You understand that no promises have been made to you as the results of the outcome of program provided by the organization and you understand services provided in the program is a collaborative effort and that the results of your progress depends on your willingness to engage in the services provided. You understand that your information is confidential with the exception to the exemption to confidentiality listed in the confidentiality and privacy sections of this document. You agree in the event of a crisis or an emergency Bloom Upstate will contact the numbers provide in the Telephone and emergency contact section. By signing below you agree and understand these provision and give your consent to receive treatment services.Name* First Date* MM slash DD slash YYYY Parent/legal guardian* First Date* MM slash DD slash YYYY Witness* First PhoneThis field is for validation purposes and should be left unchanged. Δ
