Personal Information
FOSTERING NEW BEGINNING
Participants understand the purpose of the Butterfly Program is to prepare foster youths to transition out of the foster care system by learning and achieving life skill curriculum/goals. The following topics that will be covered throughout the Butterfly Program are: Housing, Employment, Education, Financial Literacy, Daily Living/Cooking, Civic Engagement, and Healthy Relationships.
Behavior Guidelines
Participants shall be responsible for their words and actions.
Participants shall be respectful of others.
Participants shall follow directions from Staff Members, Camp Counselors and Volunteers.
Participants are not to allow cell phones or other electronic devices to disrupt ongoing
activities.
Participants are not allowed to leave the premises without permission.
Participants are not allowed to miss more than 3 sessions without an excused absence.
Participants must cancel meetings 24 hours in advance with the Care Coordinator.
Participants must make progress towards and achieve monthly goals.
Prohibited Behaviors
Endangering the health and safety of themselves, other participants, and/or staff or
volunteers. Stealing, damaging, or failing to care for the Center or personal property.
No disruptive behavior on any of the transportation vehicles or failure to comply with the drivers’ safety instructions.
Refusal to follow the behavior guidelines or inappropriate physical contact.
Using profanity or inappropriate language or displaying clothing with offensive
content. Continual disruption of the program. Bullying or acts of aggression or
violence.
Possession or use of illegal substances, tobacco, vapes or alcohol.
Possession of weapons - any object that may cause harm to another.
Steps taken for failure to follow the behavior guidelines
Staff will redirect the camper to a more appropriate behavior.
The participant will be reminded of the behavior guidelines.
If the behavior persists, staff will discuss the problem with a parent/guardian.
The staff will document the situation. The written documents will include what the behavior problem is,
what provoked the problem, and the corrective action taken.
If the problem persists to the point where a second phone call becomes necessary, The Care Coordinator may find it necessary to have the camper picked up early from our program.
If a participant's behavior at any time threatens the safety of him/her, other campers, or staff,
the parent/guardian will be notified and expected to pick-up the child immediately.
*I have read and explained all of the information provided in this document to my child. If any of the actions listed are violated by my child, it is understood that immediate dismissal from the program is expected.
I,
of
Dated:
(Sign - Parent or Guardian name above) (Print - Youth’s name above)
Staff Signature:
Client or Guardian Signature:
Education is a priority at Genesis Hopeful Haven. Students Portal provides many features for
students to download content, check assignments, view grading reports and schedule. Staff will check in on participant’s student information on a regular basis to ensure their grades are being maintained.
Participant Name:
Participant School:
Participant Grade:
Student ID:
Student Portal Password:
Will Participant Bring Their Own Laptop/Tablet:
Does the participant need a laptop provided by Miami-Dade County Public Schools?
Parent Signature:
Participant Signature:
This information is needed to register your child to Key’s to Independences
This program will allow for your child to receive all fees pertaining to getting their driver's license paid for including driving lessons.
Youth Information
License Background:
Youth First Name:
Youth Last Name:
Youth Date of Birth (mm/dd/yyyy)*:
Youth Phone (xxx-xxx-xxxx):
Youth Email:
CAREGIVER INFORMATION
Caregiver's Name:
Caregiver's Home Phone (xxx-xxx-xxxx):
Caregiver's Mobile Phone (xxx-xxx-xxxx):
Caregiver's Email
CASE MANAGER INFORMATION
Case Manager's First Name:
Case Manager's Last Name:
Case Manager's Phone (xxx-xxx-xxxx):
Case Manager's Email:
Please note that only the enrolling Parent/Guardian will be permitted to complete this form
Date:
Child’s Name:
Parent/Guardian
Cell Phone:
Authorized Visitor & PickUp Release - Please list any individual who is authorized to pick up or visit your child, including yourself. Each authorized person must be at least 21 years of age. The above-named child will not be permitted to leave the program with anyone who is not listed below. Authorized individuals will be requested to show identification to program staff. Visitors cannot be same-age friends or acquaintances. Visitors must be a Caseworker, Therapist or Professional with knowledge of the child. Children will not be released to persons who fail to provide acceptable identification upon request. Please list the responsible persons with permission to pick up or visit your child from the program.
Authorized Person Phone Number Relationship to Child
*Visitors must notify the Camp Director 12-24 hours in advance that their presence is expected. Camp activities will be in process and staff will need to make arrangements to ensure the child can be available.
Parent Guardian Print Name:
Parent Guardian Signature