!!!

!

!

Babysitter!Packet!

!!

Babysitter*Application*

**

Primary!Caregiver_________________________________________________________!

Primary!Phone!Number!_________________________________!DOB!___________________!

Address!_________________________________________!City!__________________________!

State!____________________!Zip!_____________________!

Primary!Email!____________________________________________!

Occupation!_____________________________________Employer_______________________!

Vehicle!Make/Model!________________________________!Tag!#!_______________________!

!

Secondary!Caregiver!______________________________________________________!

Secondary!Phone!Number!________________________________!DOB!___________________!

Secondary!Email!__________________________________________________________!

Occupation!______________________________________Employer!______________________!

Vehicle!Make/Model!_________________________________!Tag!#______________________!

!

Religion/Church!Affiliation___________________________________________________!

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Babysitter*Packet*!

!!!Uniting!Hope!4!Children!encourages!families!to!find!their!own!babysitters.!They!are!valuable!members!of!the!foster!family!support!team.!In!order!to!babysit!in!your!own!home,!there!are!a!few!items!UH4C!requires.!!!Below!are!the!requirements!for!babysitters!who!wish!to!babysit!in!their!own!home:!

• Drivers!License!(for!at!least!one!year)!• Background!Check!• First!Aid/CPR!Training!• Water!Safety!Training!• 2!Character!References!• Babysitter!Safety!Audit!

o This!is!a!modified!home!study!to!ensure!the!safety!of!the!home!for!the!foster!child.!

• Car!Safety!Inspection!o If!you!plan!to!transport!the!foster!child!in!your!car,!UH4C!will!

complete!a!simple!safety!inspection!of!your!car.!!!!!In!this!packet,!you!will!find!the!required!documents!UH4C!will!need.!Once!you!complete!the!packet,!you!can!bring!it!to!the!UH4C!office!or!mail!it.!If!you!have!any!questions,!don’t!hesitate!to!contact!us!!!Uniting!Hope!4!Children! ! ! ! 678\585\4686!7706B!Hampton!Place! ! ! ! info@uh4c.org!Loganville,!GA!30052!

Miscellaneous*Information*!

Background*Check!Background!checks!are!required!for!all!babysitters.!Please!fill!out!the!IntelliCorp!Background!Check!Consent!Form!and!turn!it!in!with!your!application!packet.!!!CPR/First*Aid*Training!Babysitters!must!be!CPR/First!Aid!certified!before!they!can!take!care!of!a!foster!child.!If!you!already!have!your!certificate,!place!a!copy!in!your!application!packet.!If!you!need!to!be!certified,!contact!our!office!to!see!if!we!have!any!upcoming!trainings.!Any!training!offered!through!UH4C!is!free.!!!Water*Safety*Training!Babysitters!must!complete!water!safety!training!before!they!can!take!care!of!a!foster!child.!To!find!this!training,!visit!this!website:!

http://homepoolessentials.org/!The!course!is!certified!through!American!Red!Cross.!The!cost!is!$19.95!for!the!online!course.!!!!!!If!you!have!any!questions!about!background!checks!or!trainings,!please!contact!us.!!Uniting!Hope!4!Children! ! ! ! 678\585\4686!7706B!Hampton!Place! ! ! ! info@uh4c.org!Loganville,!GA!30052!

I hereby authorize IntelliCorp to receive any CRIMINAL HISTORY record information pertaining to me,

which may be in the files of any criminal justice agency within the United States.

Print complete name: ______________________________________ Date requested: ___________ Last First Middle Maiden name or name(s) used in the past: ________________________

Date of Birth: _____________ Social Sec. #: _______________ Gender: _______ Race: _______ Current Address: ___________________________ City: __________________ Zip: ___________

I __________________ give consent to the First Baptist Church of Loganville to perform periodic crimi-nal history background checks for the duration of my volunteering/employment.

Signature: _______________________________________

BACKGROUND CHECK CONSENT FORM

!!!

CHARACTER*REFERENCE*FORM*!

The!applicant!below!would!like!to!be!accepted!by!Uniting!Hope!4!Children!for!the!purpose!of!being!a!volunteer.! If!accepted,!she/he!will!spend!time!supporting!our!clients! in!various!activities.!You!will!be!contacted!by!our!organization!to!confirm!this!reference.!!1.!Name!of!applicant:!!! ! !!Reference*Information:*!2.!Name!of!reference:!! ! !!3.!Day!Time!Telephone:!! ! !4.!Evening!Time!Telephone:!! ! !!5.!Address:!!! !

! !

!I!confirm!that!the!information!below!is!true!and!correct.!!Signature!of!the!Reference:! ! !!Date:!! ! !!

6.!How!long!have!you!known!the!applicant?!!! ! !!7.!How!do!you!know!the!applicant?!(example:!employer,!neighbor,!friend!etc.)!!! !!8.!Please!check!the!most!appropriate!box!regarding!applicant’s!abilities:!!

Abilities* Excellent* Very*Good* Good* Poor* Don’t*Know*Communication*

Skills*! ! ! ! !

Work*Quality* ! ! ! ! !Attitude* ! ! ! ! !Reliability* ! ! ! ! !Maturity* ! ! ! ! !

Helpfulness* ! ! ! ! !Ability*to*work*with*others*

! ! ! ! !

!!!!

9.!Please!describe!why!you!think!the!applicant!would!be!suitable!for!UH4C.!!! !

! !

!10.!Please!provide!any!additional!comments!about!the!applicant’s!character:!! !

! !

! !

!!Additional!Comments:!!! !

! !

! !

! !

! !

! !

! !

!!!

CHARACTER*REFERENCE*FORM*!

The!applicant!below!would!like!to!be!accepted!by!Uniting!Hope!4!Children!for!the!purpose!of!being!a!volunteer.! If!accepted,!she/he!will!spend!time!supporting!our!clients! in!various!activities.!You!will!be!contacted!by!our!organization!to!confirm!this!reference.!!1.!Name!of!applicant:!!! ! !!Reference*Information:*!2.!Name!of!reference:!! ! !!3.!Day!Time!Telephone:!! ! !4.!Evening!Time!Telephone:!! ! !!5.!Address:!!! !

! !

!I!confirm!that!the!information!below!is!true!and!correct.!!Signature!of!the!Reference:! ! !!Date:!! ! !!

6.!How!long!have!you!known!the!applicant?!!! ! !!7.!How!do!you!know!the!applicant?!(example:!employer,!neighbor,!friend!etc.)!!! !!8.!Please!check!the!most!appropriate!box!regarding!applicant’s!abilities:!!

Abilities* Excellent* Very*Good* Good* Poor* Don’t*Know*Communication*

Skills*! ! ! ! !

Work*Quality* ! ! ! ! !Attitude* ! ! ! ! !Reliability* ! ! ! ! !Maturity* ! ! ! ! !

Helpfulness* ! ! ! ! !Ability*to*work*with*others*

! ! ! ! !

!!!!

9.!Please!describe!why!you!think!the!applicant!would!be!suitable!for!UH4C.!!! !

! !

!10.!Please!provide!any!additional!comments!about!the!applicant’s!character:!! !

! !

! !

!!Additional!Comments:!!! !

! !

! !

! !

! !

! !

! !

*

Uniting!Hope!4!Children!Services!Babysitter!Home!SAFETY!AUDIT!

!

Name%of%Babysitter:%% % % % % % % % % % %% % % %Last% % %%%%%%%%%%%%%%%%%%%%%%%%%%First% % % Mi.%%Address%(City,%State,%Zip):%___________________________________________________%%%

Check!one:! !!!!_____!Initial%Certification%%_____%Recertification%!

%1.%%% The%home%and%all%structure%associated%with%the%home%are%maintained%%% in%a%clean,%safe%and%sanitary%condition%and%in%a%reasonable%state%of%% repair.% % % % % % % % % % Yes%% No%2.%%% Outdoor%recreation%equipment%on%the%grounds%of%a%primary%treatment%% facilitator%is%maintained%in%a%safe%state%of%repair.% % % % % Yes%% No% N/A%3.% Potentially%hazardous%outdoor%areas%on%the%grounds%of%or%immediately%% adjacent%to%the%Primary%Treatment%Facilitator%home%are%reasonably%% safeguarded.% % % % % % % % % Yes% No% N/A%4.%%% Bleach,%cleaning%materials,%other%poisonous%or%corrosive%household%% chemicals,%flammable%and%combustible%materials,%alcohol,%%%%%%%%%%%%%%% potentially%dangerous%tools%or%utensils,%and%electrical%equipment%or%%%%%%%%%%%%%%% machinery%in%or%on%the%grounds%of%the%home%are%stored%in%a%safe%manner.% %

locked%or%otherwise%inaccessible%to%foster%children.% % % % % Yes% No%5.% Firearms,%air%rifles,%hunting%slingshot%or%other%projectile%weapon%kept%% on%the%grounds%of%or%in%the%home%are%stored%in%a%locked%area%%% inaccessible%to%youth.% % % % % % % % Yes% No% N/A%6.% There%is%reasonable%access%to%a%working%telephone%for%emergency%

situations.% % % % % % % % % Yes% No%7.% All%locking%doors%inside%the%home%are%able%to%be%unlocked%from%either%% side.% % % % % % % % % % Yes%% No%8.% The%home%has%working%bathroom%and%toilet%facilities%located%within%the%%% home%and%connected%to%an%indoor%plumbing%system.% % % % % Yes% No% %9.% The%home%has%a%working%smoke%alarm%approved%by%“Underwriter’s%% Laboratory”%on%each%level%of%occupancy% % % % % % Yes% No%10.% All%escape%routes%are%kept%free%of%clutter%and%other%obstructions.% % % Yes% No%11.% Pets%or%domestic%animals%in%or%on%the%premises%of%the%home%are%kept%in%% a%safe%and%sanitary%manner%in%accordance%with%state%and/or%local%laws% % % Yes% No% N/A%12.% Worker%has%confirmed%that%foster%parent%knows%that%medications%in%the%%% home%must%be%double%locked.% % % % % % % Yes% No%13.% Swimming%pool%is%fenced,%with%a%locked%gate%to%prevent%unsupervised%%

access,%and%it%meets%all%applicable%community%ordinances.% % % % Yes%% No%% N/A%%

!

I!hereby!certify!that!based!on!my!observations!of!this!date,!this!home!appears!to!be!reasonably!safe!for!the!placement!of!a!foster!child.!%% % % % % % % % % % % % % %Babysitter%Signature% % % % % % % % Date%%! ! % % % % % % % % % % % %Uniting%Hope%4%Children%Staff%Signature% % % % % % Date%

1

HIPAA Notice of Privacy Practices Georgia Department of Human Services

Effective Date: August 15, 2013

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

If you have any questions about this notice, please contact: Georgia Department of Human Services HIPAA Privacy Officer HIPAA1@dhr.state.ga.us (404) 656-4421 phone (404) 657-1123 fax

The Department of Human Services (DHS) is an agency of the Executive Branch of Georgia government charged with the administration of numerous federal programs responsible for the storage, use and maintenance of medical and other confidential information. Federal and state laws establish strict requirements for these programs regarding the use and disclosure of confidential and protected information. DHS is required to comply with those laws as noted throughout this Notice.

OBLIGATIONS OF THE DEPARTMENT OF HUMAN SERVICES:

DHS is required by law to: • Maintain the privacy of protected health information;

• Give you this notice of our legal duties and privacy practices regarding health information about you; and

• Follow the terms of our notice currently in effect.

HOW DHS MAY USE AND DISCLOSE HEALTH INFORMATION:

The following describes the ways DHS may use and disclose health information that identifies you (“Health Information”). Except for the purposes described below, DHS will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to the HIPAA Privacy Officer at the contact information above.

Nathan Deal, Governor Keith Horton, Commissioner

Georgia Department of Human Services ▪ Office of the General Counsel ▪ Suite 29.250 ▪ Two Peachtree Street, NW ▪ Atlanta, Georgia 30303-3142 ▪ 404-657-9761 ▪ 404-657-1123 (Fax)

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For Treatment. DHS may use and disclose Health Information for your treatment and to provide you with treatment-related health care services. For example, DHS may disclose Health Information to doctors, nurses, technicians, or other personnel who are involved in your medical care and need the information to provide you with medical care.

For Payment. DHS may use and disclose Health Information so that DHS or others may bill and receive payment related to your care, an insurance company, or a third party for the treatment and services you received. For example, DHS may provide your health plan information so that treatment may be paid for.

For Health Care Operations. DHS may use and disclose Health Information for health care operations purposes. These uses and disclosures are necessary to make sure that quality care is received and to operate, manage, and administer the functions of the agency. For example, DHS may use and disclose information to make sure the medical care you receive is of the highest quality. DHS also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities.

Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. DHS may use and disclose Health Information to contact you to remind you of an appointment with a physician. DHS also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care. When appropriate, DHS may share Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. DHS also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

Research. Under certain circumstances, DHS may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before DHS uses or discloses Health Information for research, the project will go through a special approval process. Even without special approval, DHS may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any Health Information.

SPECIAL SITUATIONS:

As Required by Law. DHS will disclose Health Information when required to do so by international, federal, state or local law.

To Avert a Serious Threat to Health or Safety. DHS may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.

Business Associates. DHS may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, DHS may utilize the services of a separate entity to perform billing services. All DHS business associates are obligated to protect the privacy of your

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information and are not allowed to use or disclose any information other than as specified in our contract.

Organ and Tissue Donation. If you are an organ donor, DHS may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, DHS may release Health Information as required by military command authorities. DHS also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.

Workers’ Compensation. DHS may release Health Information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. DHS may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if it is believed a patient has been the victim of abuse, neglect or domestic violence. DHS will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. DHS may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Data Breach Notification Purposes. DHS may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, DHS may disclose Health Information in response to a court or administrative order. DHS also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. DHS may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. DHS may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person

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or determine the cause of death. DHS also may release Health Information to funeral directors as necessary for their duties.

National Security and Intelligence Activities. DHS may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

Protective Services for the President and Others. DHS may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.

Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, DHS may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.

USES AND DISCLOSURES THAT REQUIRE DHS TO PROVIDE YOU AN OPPORTUNITY TO OBJECT AND OPT

Individuals Involved in Your Care or Payment for Your Care. Unless you object, DHS may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, DHS may disclose such information as necessary if it is determined that it is in your best interest based on the professional judgment of DHS.

Disaster Relief. DHS may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. DHS will provide you with an opportunity to agree or object to such a disclosure whenever it is practical to do so.

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES

The following uses and disclosures of your Protected Health Information will be made only with your written authorization:

1. Uses and disclosures of Protected Health Information for marketing purposes; and

2. Disclosures that constitute a sale of your Protected Health Information

Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to DHS will be made only with your written authorization. If you do provide DHS an authorization, you may revoke it at any time by submitting a written revocation to the above-referenced Privacy Officer. Upon receipt, DHS will no longer disclose Protected Health Information under the authorization. However, disclosures made in reliance upon your authorization before you revoked it will not be affected by the revocation.

YOUR RIGHTS:

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You have the following rights regarding Health Information DHS has about you:

Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to the above referenced HIPAA Privacy Officer. DHS has up to 30 days to make your Protected Health Information available to you and DHS may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. DHS may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program. DHS may deny your request in certain limited circumstances. If DHS does deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and DHS will comply with the outcome of the review.

Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. DHS will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request, your record will be provided in either our standard electronic format. If you do not want this form or format, a readable hard copy form will be provided. DHS may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information.

Right to Amend. If you feel that Health Information DHS has is incorrect or incomplete, you may request DHS to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to the above-referenced HIPAA Privacy Officer.

Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures DHS made of Health Information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to the above-referenced HIPAA Privacy Officer.

Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information DHS uses or disclosed for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information DHS discloses to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that DHS not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to the above-referenced HIPAA Privacy Officer. DHS is not required to agree to your request unless you are requesting DHS restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid “out-of-pocket” in full. If DHS

6

agrees, we will comply with your request unless the information is needed to provide you with emergency treatment.

Right to Request Confidential Communications. You have the right to request that DHS communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that DHS only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to the above-referenced HIPAA Privacy Officer. Your request must specify how or where you wish to be contacted. DHS will accommodate reasonable requests.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may request a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, please contact the above-referenced HIPAA Privacy Officer.

CHANGES TO THIS NOTICE:

DHS reserves the right to change this notice and make the new notice apply to Health Information already obtained as well as any information received in the future. DHS will post a copy of the current notice at our office. The notice will contain the effective date on the first page, in the top right-hand corner.

COMPLAINTS:

If you believe your privacy rights have been violated, you may file a complaint, in writing, by contacting the above-referenced HIPAA Privacy Officer. You will not be penalized for filing a complaint. You may also file with the Secretary of the Department of Health and Human Services. For more information on HIPAA privacy requirements, HIPAA electronic transactions and code sets regulations and the proposed HIPAA security rules, please visit ACOG’s web site, www.acog.org, or call (202) 863-2584. ______________________________________________________________________ I have read, understand, and acknowledge receipt of the DHS HIPAA Notice of Privacy Practices.

__________________________ __________________________ Signature Date __________________________ Print Name

Social'Media'Policy''

!To!protect!and!ensure!the!dignity!of!children,!the!safety!of!families,!and!the!well7being!of!all!involved!in!the!foster!care!process!no!pictures!or!videos!of!foster!children!shall!be!on!Facebook,!Instagram,!Snapchat,!Twitter!or!any!other!web!based!site.!Volunteers!shall!do!all!they!can!to!protect!the!dignity!of!the!foster!children.!Children!should!never!be!made!to!feel!advertised!or!marketed.!!!!!I!have!read!and!agreed!to!the!above!stated!policy!!!!_______________________________________________________________________!!!!! !!!!!!!!!!!!!!!!!!!!!!Volunteer!Signature!!!!________________________________________________________________________!!!_______________________!! ! ! Print!Name! ! ! ! ! ! Date!!!!_________________________________________________________________________!Parent/Guardian!Signature!(if!volunteer!is!under!18!years!of!age)!!_________________________________________________________________________!! ! ! Print!Name! !

! Volunteer)Waiver,)Release,)Hold)Harmless)and)Indemnification)Agreement)

)I!have!agreed!to!serve!as!a!volunteer!for!Uniting!Hope!4!Children!and!I!

recognize!that!my!volunteer!participation!is!a!privilege!afforded!to!me!by!Uniting!Hope!4!Children.!I!fully!understand,!appreciate!and!assume!all!of!the!risks!associated!with!my!volunteer!duties.!In!exchange!for!my!participation!I!hereby!agree!to!the!following:!

!! 1.!! I!voluntarily!waive,!release!and!hold!harmless!Uniting!Hope!4!Children,!its!elected!and!appointed!officials,!officers,!employees,!agents!and!other!volunteers!from!any!and!all!claims,!causes!of!actions!and!damages!for!bodily!injury!or!death!that!I!may!suffer!as!a!result!of,!or!in!any!manner!connected!with,!directly!or!indirectly,!my!participation!as!a!Uniting!Hope!4!Children!volunteer!when!such!bodily!injury!or!death!is!the!result!of!my!own!negligent!or!intentional!acts!or!omissions!or!those!of!another!volunteer.!I!understand!that!this!waiver!and!release!precludes!my!right!to!recovery!of!damages!in!the!event!that!I!am!injured!in!the!course!of!performing!my!volunteer!duties.!!!! 2.!! I!shall!defend,!hold!harmless!and!indemnify!Uniting!Hope!4!Children,!its!elected!and!appointed!officials,!officers,!employees,!agents!and!other!volunteers,!from!and!against!all!damages,!claims,!liabilities,!causes!of!action,!judgments,!settlements,!costa!and!expenses!(including,!but!not!limited!to,!reasonable!expert!witness!and!attorney!fees)!that!may!at!any!time!arise!or!be!claimed!by!any!person!as!a!result!of!bodily!injury,!death!or!property!damage,!or!as!a!result!of!any!other!claim!or!cause!of!action!of!any!nature!whatsoever,!arising!from!or!in!any!manner!connected!with,!directly!or!indirectly,!my!negligent!or!intentional!acts!or!omissions!in!performing!my!volunteer!duties.!!!! I!have!read,!fully!understand,!and!agree!to!the!assumption!of!risk,!waiver,!release,!hold!harmless!or!indemnification!set!forth!above.!!!_______________________________________________________________________!! ! ! Volunteer!Signature!!________________________________________________________________________!!_______________________!! ! ! Print!Name!! ! ! ! ! Date!!________________________________________________________________________!Parent/Guardian!Signature!(if!volunteer!is!under!18!years!of!age)!!________________________________________________________________________!! ! ! Print!Name!

DISCIPLINE)POLICY)))

Purpose:))

To#ensure#the#safety#and#well#being#of#every#child.##UH4C#follows#the#Georgia#State#DFCS#Discipline#Standards#and#no#physical#and/or#emotional#punishment#shall#occur#in#a#UH4C#Foster#Home.##UH4C#provides#foster#parents#with#training#on#appropriate#behavior#management#techniques#and#reviews#those#disciplinary#actions#that#are#prohibited.#All#UH4C#Foster#Parents#are#required#to#sign#the#UH4C#Discipline#Guidelines#during#training.#A#copy#is#provided#to#the#parents#and#added#to#the#foster#home#record.#Furthermore,#this#policy#is#reviewed#again#with#foster#parents#when#each#new#child#is#placed#in#their#home.##The#UH4C#Discipline#Guidelines#states#that#they#will#follow#this#policy#during#any#placement.##UH4C#utilizes#The#Division#of#Family#and#Children#Services#Discipline#Policy#in#that#any#physical#or#emotional#punishment#to#a#foster#child#is#prohibited.#Physical#punishment#is#defined#as#any#deliberately#inflicted#pain#to#the#body#of#the#individual.#UH4C#Foster#Parent(s)#are#required#to#know#the#difference#between#punishment#and#discipline.###In#the#event#the#Discipline#Policy#is#broken,#UH4C#will#report#immediately#to#DFCS#and#the#home#will#be#investigated#and#possibly#closed.#This#is#the#sole#discretion#of#DFCS.#All#of#this#will#be#documented#on#the#Incident#Intake#Form.##Discipline#is#instruction#K#a#standard#of#behavior#that#is#maintained#consistently#and#with#authority.##Punishment#is#one#means#of#enforcing#discipline,#usually#through#the#least#effective#means.#Discipline#is#a#learning#process#for#children.#Discipline#should#help#a#child#reach#a#goal#of#controlling#his#or#her#own#behavior,#acquiring#selfKdiscipline.##Foster#parents#may#have#used#some#forms#of#physical#and#emotional#punishment#with#their#own#biological#children.#We#must#remember,#however,#that#children#raised#in#an#accepting#and#loving#family#which#is#able#to#meet#their#needs#tolerate#punishment#in#a#different#way#than#children#removed#from#their#families#because#of#severe#neglect#and#abuse.#Children#entering#foster#care#usually#feel#at#least#one#and#often#all#of#the#following:##

• #Negative#attention#is#better#than#no#attention#at#all#• #The#natural#response#to#frustration,#disappointment,#anger,#etc.,#is#physical#

or#verbal##violence#

• #Any#form#of#physical#action#can#lead#to#severe#abuse#creating#fear#and#mistrust#

• They#are#not#lovable,#which#is#reinforced#by#physical#pain#and#verbal#demeaning#

• They#are#the#reason#the#family#is#not#together#and#deserve#punishment#!At!UH4C,!we!believe!that!positive!encouragement!and!instruction!is!one!of!the!best!ways!to!promote!healthy!habits!in!children.!We!accomplish!this!by!utilizing!a!chart!and!reward!system!in!which!we!work!closely!with!foster!parents!and!their!foster!children.!!Each!month,!the!child!will!receive!prizes!for!the!number!of!stars!they!have!earned!on!their!chart.!They!can!never!lose!stars,!but!can!always!gain!more.!The!family!will!bring!the!child!to!the!agency!to!receive!a!prize.!We!believe!this!will!show!a!partnership!between!the!families!and!the!agency.!!!!!!!!!!(See!attached!Reward!Chart)!

)UH4C)Accepts)the)Following)Methods)of)Discipline:)#

• Reinforce#Acceptable#Behavior#K#Examples:#Honest#praise,#special#privileges#and#treats,#additional#time#spent#with#the#child,#and#awards#such#as#stars#or#smiley#faces#on#a#door#or#bulletin#board.##Reinforcement#should#be#made#immediately#and#frequently#when#positive#changes#(no#matter#how#small)#are#observed.#

#• #Use#Logical#Consequences#for#the#Behavior#–#Examples:#If#you#leave#your#

bike#out,#you#can't#ride#it#tomorrow.#If#you#go#in#the#street,#you#have#to#come#inside.#If#you#can't#get#up#on#time,#you#will#have#to#go#to#bed#30#minutes#earlier.#

#• Criticize#the#Behavior,#Not#the#Child#K#when#talking#with#the#child.#It#is#helpful#

to#think#in#terms#of#"you#messages"#and#"I#messages."#The#"youKmessage"#lays#blame#and#conveys#criticism#of#the#child.#It#suggests#that#the#child#is#at#fault.#It#is#simply#a#verbal#attack.#In#contrast,#an#"I#message"#simply#describes#how#the#behavior#makes#you#feel.#The#message#focuses#on#you,#not#the#child.#It#reports#how#you#feel.#It#does#not#assign#blame.#Example:#"I#can't#hear#the#television#when#there#is#so#much#noise.#I#would#like#to#be#able#to#hear#it."#

#• Loss#of#Privileges#K#Example:#Television,#telephoning#friends,#playing#with#a#

specific#toy.#Make#this#time#appropriate#according#to#the#child's#age,#i.e.#take#the#TV#away#for#an#hour,#not#a#day.#It#is#more#important#to#use#a#positive#reinforcement#than#punishment#to#control#behavior.#

#• #Grounding#K#Example:#Restricting#the#child#to#the#house#or#yard#or#sending#

the#child#out#of#the#room#and#away#from#the#family#activity#for#a#short#period#of#time.#Be#careful#to#make#the#time#appropriate.#Use#the#latter#restrictions#

judiciously#making#sure#the#child#realizes#the#purpose#is#to#help#him#regain#control#of#his/her#behavior.#

#• #Helping#Children#Deal#With#and#Manage#Their#Own#Behavior#K#Example:#If#

the#child#is#fighting,#have#him#or#her#hit#a#pillow.#Explain#calmly#that#to#feel#angry#is#ok,#but#that#to#hurt#others#or#the#property#of#others#is#not#okay.#This#requires#much#repetition#and#practice.#

#• #ReKDirect#the#Child's#Activity#K#Example:#Suggest#the#child#play#with#a#toy#

instead#of#a#sharp#object.##

#• TimeKOut#from#Activities#K#Example:#With#younger#children,#sit#them#in#a#

chair#for#a#few#minutes#and#possibly#use#a#timer#so#that#they#can#understand#the#time#frame.#A#good#rule#of## thumb#is#one#minute#for#every#year,#i.e.,#5#years#of#age:#5#minutes.#

#• #Specific#Problem#Behaviors#K#If#the#child#is#not#being#truthful,#try#to#

understand#the#reason#and#the#motivation#behind#the#child's#action.#Often#the#child#is#seeking#acceptance,#rather#than#trying#to#be#deceitful.#In#the#case#of#tantrums#or#other#troubling#behaviors#the#foster#parent#should#contact#the#UH4C#case#manager#to#discuss#the#behaviors#and#create#a#behavior#plan#for#the#child.#

)UH4C)PROHIBITS)the)Following)Disciplinary)Practices:)#

• Spanking,)Slapping,#Switching,#or#hitting#a#child#with#your#hand#or#any#object#• Corporal#punishment#• Shaking,#pinching,#or#biting#• Tying#a#child#with#a#rope#or#similar#item#• Denying#mail,#family#visits,#and#telephone#contacts#with#family##• Denying#activities#with#the#UH4C#or#DFCS#Case#Managers.#• Criticizing#the#child's#family#or#the#child's#experiences#with#the#family#• Humiliating#or#degrading#punishment#which#subjects#the#child#to#ridicule,#

such#as:## Verbal#Abuse## Cutting#or#combing#the#child's#hair#for#punishment## Name#calling#and#public#scolding## Forcing#any#child#to#wear#clothing#or#accessories#usually#associated#with#the#other#sex#

• Threatening#a#child#with#removal#from#the#foster#home.#This#creates#fear,#anger,#and#anxiety.#

• Locking#a#child#in#a#room/closet#or#outside#the#home#• Group#punishment#for#the#misbehavior#of#an#individual#child#

• Delegating#authority#for#punishment#to#or#allowing#punishment#by#other#children#or#adults#

• Destroying#the#child's#property#• Manual#holds,#chemical#and/or#mechanical#restraints.#Manual#holds#are#not#a#

form#of#discipline#to#restrict#runaways#unless#the#pose#a#threat#of#physical#harm#to#themselves#or#others.#

• Denial#of#food#or#hydration#• Assignment#of#excessive#or#unreasonable#work#tasks#not#related#to#the#

child's#misbehavior#• Denial#of#shelter,#clothing,#and#personal#needs#• Denial#of#essential#services#• Denial#of#sleep#• Seclusion#or#confinement#of#a#child#in#a#room#• ESIs#are#prohibited#discipline#measures#and#should#only#be#used#for#the#

protection#of#foster#child,#staff,#foster#parent,#or#other#children.###Any#form#of#spanking#or#physical#discipline#will#be#considered#abuse#and#reported#to#the#state#immediately.###I#HAVE#READ#AND#AGREE#TO#ABIDE#BY#THE#DISCIPLINE#POLICY#OF#UH4C.#FAILURE#TO#DO#SO#MAY#RESULT#IN#THE#CLOSING#OF#MY#FOSTER#HOME.###

_______________________________________# # _________________##Volunteer#Signature# # # # # Date##_______________________________________# # _________________##Print#Name## # # # # # Date##________________________________________###############_________________________________________#Parent/Guardian#(if#under#18)# # # Print#Name####

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