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psa with Tania Perez q�12� PROFESSIONAL SERVICES AGREEMENT BETWEEN THE CITY OF MIAMI BEACH, FLORIDA AND TANIA PEREZ FOR YOUTH SERVICES RELATED TO THE CITY'S MORNING ALL STARS PROGRAM THIS AGREEMENT made and entered into this 1 st day of August, 2012, by and between the CITY OF MIAMI BEACH, FLORIDA (hereinafter referred to as City), having its principal offices at 1700 Convention Center Drive, Miami Beach, Florida, 33139, and TANIA PEREZ, (hereinafter referred to as Contractor), whose address is 7955 Hawthorne Ave. Miami Beach, FL 33141. SECTION 1 1.1 DEFINITIONS Agreement: This Agreement between the City and Contractor, and any exhibits and/or attachments hereto. City Manager: The Chief Administrative Officer of the City. Contractor: For the purposes of this Agreement, Contractor shall be deemed to be an independent contractor, and not an agent or employee of the City. Services: All services, work and actions by the Contractor performed pursuant to or undertaken under this Agreement, as described in Section 2. Fee (Compensation): Amount paid to the Contractor to cover the costs of the Services. Risk Manager: The Risk Manager of the City, with offices at 1700 Convention Center Drive, Third Floor, Miami Beach, Florida 33139, telephone number (305) 673-7000, Ext. 6435, and fax number (305) 673-7023. City of Miami Beach-TANIA PEREZ Page 1 of 13 Miami Beach Morning All Stars Program SECTION 2 SCOPE OF WORK (SERVICES) The Contractor will provide assistance to the Morning All Stars program as an instructor, assist with recruitment, and assist with completion of intake forms for up to One Hundred Eighty (180) youth and their families in accordance with The Morning All Stars Program Grant, dated August 1, 2012. The scope of work to be performed by Contractor is further detailed in Exhibit 'A," entitled "Scope of Services." The Contractor shall report to the City of Miami Beach, Neighborhood Services Department, Office of Community Services, Division Director. SECTION 3 COMPENSATION 3.1 FIXED FEE Contractor shall be compensated for the Services, as set forth in Section 2 and Exhibit "A", as follows: (a) attendance to All Stars Online Training; (b) implementation 'of the All Stars curriculum to several cohorts throughout the year; and (c) recruitment and completion of Morning All Stars' intake and consent forms, at Nineteen Dollars and Forty-Four Cents 19.44 per each' hour worked for u to Y ($ ) P P 428.36 hours, for a maximum not to exceed Eight Thousand Three Hundred Twenty- Seven Dollars ($8,327). Contractor's compensation shall be further subject to and conditioned upon all or any portion of the Services to be provided herein being allowable and within the Scope of Services delineated in Exhibit "A". Notwithstanding the preceding, Contractor's total compensation during the term of this Agreement shall not exceed the maximum allowable sum of Eight Thousand Three Hundred Twenty-Seven Dollars ($8,327). 3.2 INVOICING Contractor shall submit a biweekly invoice (every two weeks) and accompanying time sheets indicating hours worked which includes an itemized, detailed description of the Services, or portions thereof, provided and cost(s) for same. Invoices and supporting documentation shall be submitted to Maria Ruiz, Division Director, Office of Community Services, 1700 Convention Center Drive, Miami Beach, Florida, 33139. 3.3 METHOD OF PAYMENT Payments shall be made within thirty (30) days of the date of invoice, in a manner satisfactory to and as approved and received by the City Manager and/or his designee, who shall be the Division Director, Office of Community Services. City of Miami Beach-TANIA PEREZ Page 2 of 13 Miami Beach Morning All Stars Program SECTION 4 GENERAL PROVISIONS 4.1 RESPONSIBILITY OF THE CONTRACTOR With respect to the performance of the Services, the Contractor shall exercise that degree of skill, care, efficiency and diligence normally exercised by recognized professionals with respect to the performance of comparable services. In its performance of the Services, the Contractor shall comply with all applicable laws, ordinances, and regulations of the City, Miami-Dade County, the State of Florida, and the federal government, as applicable. 4.2 PUBLIC ENTITY CRIMES . A State of Florida Form PUR 7068, Sworn Statement under Section 287.133(3)(a) Florida Statute on Public Entity Crimes shall be filed with the City's Procurement Division, prior to commencement of the Services herein. 4.3 DURATION AND EXTENT OF AGREEMENT (TERM) The term of this Agreement shall commence upon execution of this Agreement by all parties hereto, and shall terminate on July 31, 2013. 4.4 TIME OF COMPLETION The Services to be rendered by the Contractor shall be commenced upon receipt of a written Notice to Proceed from the City subsequent to execution of the Agreement by the parties, and shall be completed no later than July 31, 2013. 4.5 INDEMNIFICATION Contractor agrees to indemnify and hold harmless the City of Miami Beach and its officers, employees and agents, from and against any and all actions, claims, liabilities, losses, and expenses, including, but'not limited to, attorneys' fees, for personal, economic or bodily injury, wrongful death, loss of or damage to property, at law or in equity, which may arise or be alleged to have arisen from the negligent acts, errors, omissions or other wrongful conduct of the Contractor, its employees, agents, sub-consultants, or any other person or entity acting under Consultant's control, in connection with the Contractor's performance of the Services pursuant to this Agreement; and to that extent, the Contractor shall pay all such claims and losses and shall pay all such costs and judgments which may issue from any lawsuit arising from such claims and losses, and shall pay all costs and attorneys' fees expended by the City in the defense of such claims and losses, including appeals. City of Miami Beach-TANIA PEREZ Page 3 of 13 Miami Beach Morning All Stars Program The Contractor's obligation under this Subsection shall not include the obligation to indemnify the City of Miami Beach and its officers, employees and agents, from and against any actions or claims which arise or are alleged to have arisen from negligent acts or omissions or other wrongful conduct of the City and its officers, employees and agents. The parties each agree to give the other party prompt notice of any claim .coming to its knowledge that in any way directly or indirectly affects the other party. 4.6 TERMINATION, SUSPENSION AND SANCTIONS 4.6.1 Termination for Cause If the Contractor shall fail to fulfill in a timely manner, or otherwise violate any of the covenants, agreements, or stipulations material to this Agreement, the City shall thereupon have the right to terminate the Services then remaining to be performed. Prior to exercising its option to terminate for cause, the City shall notify the Contractor of its violation of the particular terms of this Agreement and shall grant Contractor seven (7) days to cure such default. If such default remains uncured after seven (7) days, the City, upon three (3) days' notice to Contractor, may terminate this Agreement and the City shall be fully discharged from any and all liabilities, duties and terms arising out of/or by virtue of this Agreement. Notwithstanding the above, the Contractor shall not be relieved of liability to the City for damages sustained by the City by any breach of the Agreement by the Contractor. The City, at its sole option and discretion, shall additionally be entitled to bring any and all legal/equitable actions that it deems to be in its best interest in order to enforce the City's right and remedies against the defaulting party. The City shall be entitled to recover all costs of such actions, including reasonable attorneys' fees. To the extent allowed by law, the defaulting party waives its right to jury trial and its right to bring permissive counter claims against the City in any such action. - 4.6.2 Termination for Convenience of City NOTWITHSTANDING SECTION 4.6.1, THE CITY MAY ALSO, FOR ITS CONVENIENCE AND WITHOUT CAUSE, TERMINATE THIS AGREEMENT AT ANY TIME DURING THE TERM HEREOF BY GIVING WRITTEN NOTICE TO CONSULTANT OF SUCH TERMINATION, WHICH SHALL BECOME EFFECTIVE SEVEN (7) DAYS FOLLOWING RECEIPT BY THE CONSULTANT OF THE WRITTEN TERMINATION NOTICE. IN THAT EVENT, ANY FINISHED OR UNFINISHED DOCUMENTS AND OTHER MATERIALS PREPARED AND OR OTHERWISE COMPILED BY CONSULTANT PURSUANT TO ITS PROVISION OF THE SERVICES City of Miami Beach-TANIA PEREZ Page 4 of 13 Miami Beach Morning All Stars Program CONTEMPLATED IN SECTION 2 AND IN EXHIBIT "A", SHALL BE PROMPTLY ASSEMBLED AND DELIVERED TO THE CITY, AT CONSULTANT'S SOLE COST AND EXPENSE. IF THE AGREEMENT IS TERMINATED BY THE CITY AS PROVIDED IN THIS SUBSECTION, CONSULTANT SHALL BE PAID FOR ANY SERVICES SATISFACTORILY PERFORMED, AS DETERMINED BY THE CITY 'AT ITS SOLE DISCERTION, UP TO THE DATE OF TERMINATION; PROVIDED, HOWEVER, THAT AS A CONDITION PRECEDENT TO SUCH PAYMENT, CONSULTANT SHALL HAVE DELIVERED ANY AND ALL DOCUMENTS, MATERIALS, ETC, TO CITY, AS REQUIRED HEREIN. 4.6.3 Termination for Insolvency The City also reserves the right to terminate the remaining Services to be performed in the event the Contractor is placed either in voluntary or involuntary bankruptcy or makes an assignment for the benefit of creditors. In such event, the right and obligations for the parties shall be the same as provided for in Section 4.6.2. 4.6.4 Sanctions for Noncompliance with Nondiscrimination Provisions In the event of the Contractor's noncompliance with the nondiscrimination provisions of this Agreement, as applicable, the City shall impose.such sanctions as the City or the State of Florida may determine to be appropriate, including but not limited to, withholding of payments to the Contractor under the Agreement until the Contractor complies and/or cancellation, termination or suspension of the Services and/or the Agreement. In the event the City cancels or terminates the Services and/or the Agreement pursuant to this Subsection the rights and obligations of the parties shall be the same as provided in Section 4.6.2. 4.7 CHANGES AND ADDITIONS Any changes and additions to the terms of this Agreement shall be by a written amendment, signed by the duly authorized representatives of the City and Contractor. No alteration, change, or modification of the terms of this Agreement shall be valid unless amended in writing, signed by the parties hereto, and approved by the City. 4.8 OWNERSHIP OF DOCUMENTS Any changes and additions to the terms of this Agreement shall be by a written amendment, signed by the duly authorized representatives of the City and Contractor. No alteration, change, or modification of the terms of this Agreement shall be valid unless amended in writing, signed by the parties hereto, and approved by the City. City of Miami Beach-.TANIA PEREZ Page 5 of 13 Miami Beach Morning All Stars Program 4.9 ASSIGNMENT, TRANSFER OR SUBCONTRACTING The Contractor shall not subcontract, assign, or transfer any work under this Agreement without the prior written consent of the City Manager which consent, if granted at all, shall be at the Manager's sole and absolute discretion. 4.10 EQUAL EMPLOYMENT OPPORTUNITY In connection with the performance of this Agreement, the Contractor shall not discriminate against any employee or applicant for employment because of race, color, religion, ancestry, sex, age, and national origin, place of birth, marital status, or physical handicap. The Contractor shall take affirmative action to ensure that applicants are employed and that employees are treated during their employment without regard to their race, color, religion, ancestry, sex, age, national origin, place of birth, marital status, disability, or sexual orientation, as applicable. 4.11 NO CONFLICT OF INTEREST The Contractor agrees to adhere to and be governed by the Metropolitan Miami-Dade County Conflict of Interest Ordinance, as same may be amended from time to time; and by City of Miami Beach Code, as same may be amended from time to time. The Contractor covenants that it presently has no interest and shall not acquire any interest, direct or indirectly which should conflict in any manner or degree with the performance of the Services. The Contractor further covenants that in the performance of this Agreement, no person having any such interest shall knowingly be employed by the Consultant. No member of or delegate to the Congress of the United States shall be admitted to any share or part of this Agreement or to any benefits arising there from. 4.12 PATENT RIGHTS; COPYRIGHTS; CONFIDENTIAL FINDINGS Any patentable result arising out of this Agreement, as well as all information, design specifications, processes, data and findings, shall be made available in to the City, for public 'use. perpetuity Y� P No reports, other documents, articles or devices produced in whole or in part under this Agreement shall be the subject of any application for copyright or patent by or on behalf of the Contractor or its employees or subcontractors. 4.13 NOTICES All notices and communications relating to the day-to-day activities shall be exchanged between a project manager appointed by the Contractor and the program coordinator designated by the City Manager, who shall be Office of Community Services, Division Director. The Contractor's project manager shall be City of Miami Beach-TANIA PEREZ Page 6 of 13 Miami Beach Morning All Stars Program designated following execution of this Agreement by the parties and prior to commencement of the Services. All other notices and communications in writing required or permitted hereunder may be delivered personally to the representatives of the Contractor and the City listed below or may be mailed by registered mail. Until changed by,notice in writing, all such notices and communications shall be addressed as follows: TO CONTRACTOR: Tania Perez 7955 Hawthorne Ave. Miami Beach, FL 33141 (786) 797-5051 TO CITY: City of Miami Beach Office of Community Services Attn: Maria L. Ruiz, Director 1700 Convention Center Drive Miami Beach, Florida 33139 (305) 673-7491 4.14 LITIGATION JURISDICTION/VENUE This Agreement shall be governed by, and construed in accordance with, the laws of the State of Florida, both substantive and remedial, without regard to principles of conflict of laws. The exclusive venue for any litigation arising out of the Agreement shall be Miami-Dade County, Florida, if in State court, and the U.S. District Court, Southern District of Florida, if in federal court. BY ENTERING INTO THIS AGREEMENT, CONTRACTOR AND CITY EXPRESSLY WAIVE ANY RIGHTS EITHER PARTY MAY HAVE TO A TRIAL BY JURY OR ANY CIVIL LITIGATION RELATED TO, OR ARISING OUT OF, THIS AGREEMENT. 4.15 ENTIRETY OF AGREEMENT This writing and any exhibits and/or attachments incorporated (and/or otherwise referenced for incorporation) herein embody the entire Agreement and understanding between the parties hereto, and there are no other agreements and understandings, oral or written, with reference to the subject matter hereof that are not merged herein and superseded hereby. City of.Miami Beach-TANIA PEREZ Page 7 of 13 Miami Beach Morning All Stars Program 4.16 LIMITATION OF CITY'S LIABILITY The City desires to enter into this Agreement only if in so doing the City can place a limit on the City's liability for any cause of action for money damages due to an alleged breach by the City of this Agreement, so that its liability for any such breach never exceeds the sum of $1,000. Contractor hereby expresses its willingness to enter into this Agreement with Consultant's recovery from the City for any damage action for breach of contract to be limited to a maximum amount of $1,000. Accordingly, and notwithstanding any other term or condition of this Agreement, Contractor hereby agrees that the City shall not be liable to the Contractor for damages in an amount in excess of $1,000 for any action or claim for breach of contract arising out of the performance or non-performance of any obligations imposed upon the City by this Agreement. Nothing contained in this paragraph or elsewhere in this Agreement is in any way intended to be a waiver of the limitation placed upon the City's liability as set forth in Section 768.28, Florida Statutes. [REMAINDER OF THIS PAGE LEFT INTENTIONALLY BLAND(] City of Miami Beach-TANIA PEREZ Page 8 of 13 Miami Beach Morning All Stars Program IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by their appropriate officials, as of the date first entered above. FOR CITY: CITY OF MIAMI BEACH, FLORIDA ATTEST: By: City CI rk ty Manager 13- 12, Date -- Date . . APP. .. •'9� FOR CONTRACTOR: ATTEST. =� y By: vim Witness Signa ure Tania Perez �C� 10► �� �C'� Witness Printed Name 12= Date Date APPROVED AS TO FORM&LANGUAGE R-FOR CUTiON • -' cv ltiti�' City of Miami Beach-TANIA PEREZ orn PacP§tgf 13 Miami Beach Morning All Stars Program 1 EXHIBIT "A" "SCOPE OF SERVICES" The Contractor agrees to provide the following services to youth referred to the Success University program: Service Units of Documentation of Service Intake & Consent Forms 180 1 Assist with Completion and execution of the following documents: ■ The Children's Trust Child Information Form i The Children's Trust Photography/Video I i Release Form ■ City of Miami Beach Morning All Stars Program Parental Consent& Information Release City of Miami Beach Notice of Privacy Practice ■ City of Miami Beach Morning All Stars Program I Emergency Care Authorization Form ■ City of Miami Beach Morning All Stars Program Discipline and Attendance Agreement ■ City of Miami Beach Morning All Stars Program Pick Up/Drop Off Consent Form I ■ City of Miami Beach Morning All Stars program Referral Out Form I Recruitment and Referral of 180 1 Distribution and/or completion of the following Participants documents: i ■ City of Miami Beach Morning All Stars Brochures ■ City of Miami Beach Morning All Stars flyers (individual cohorts with specific time & location) ' Referral of potential participants from Nautilus Middle School meeting criteria i i Instructor 52 Implement All Stars curriculum to various cohorts throughout the year. Related Definitions: Intake & Consent — The Intake provides prospective clients with an overview of Morning All Stars program and the benefits and expectations of program participation. Parental consents required for program participation are executed at this time enabling the provision of further services. The Intake marks the initial consent for service and establishes the appointment for the completion of the Assessment. A copy of the intake & consent forms are attached as Exhibit B. City of Miami Beach-TANIA PEREZ Page 10 of 13 Miami Beach Morning All Stars Program Recruitment and Referrals — Recruitment addresses the identification of a specific client need and the subsequent referral to Morning All Stars to address the need. These referrals must be documented using the City of Miami Beach Morning All Stars Referral Form. A copy of the form is attached as Exhibit C. Service Deliverables Services must be delivered as follows: Service Unit of Service Service Location Timefrarne Intake & Consent 180 School Upon consent of client Forms Recruitment and 180 School Upon identification of Referral of Participants need Instructor 52 School 13 session x 4 cohorts throughout the 2012- 2013 contract year Service Benchmarks Benchmark(s) Intake & Consent Forms • Completed Intake & Consents with all signatures and dates. Recruitment and Referral of 40% of participants from referrals Participants Instructor • On pace with All Stars Curriculum timeline • Participants are observed to be engaged -in the process/activity • Instructor is prepared for each session Penalties for Failure to Perform If the Contractor is unable to fulfill the contracted service level within the allocated timeframe for each service component, the City reserves the right to reduce service levels accordingly across the funded service spectrum. If the Contractor is .unable to fulfill the contracted service level and the City subsequently reduces service and funding levels, the City reserves the right to select another vendor to fulfill the remaining service units. The City will select the alternate vendor at its sole discretion. City of Miami Beach-TANIA PEREZ Page 11 of 13 Miami Beach Morning All Stars Program Employee/ Contractor File Review The following documentation must be included in the employee/contractor file for those employees/contractors providing services under this contract. The following must be included in the employee files: • Employment Application • Evidence of degree/credentials • Job Description,Signed by Employee • Evidence of Required Experience ® Florida Background Criminal Screening • National FBI Background Criminal Screening (Level2) • Affidavit of Good Moral Character • Proof of Knowledge of Policies & Procedures • Confidentiality Agreement Re: Client Information • Documentation of Agency Training/In-Service Training 1-9 Verification on File Monitoring & Performance Reviews The City of Miami Beach reserves the right to inspect, monitor and/or audit the Contractor to ensure contractual compliance. This includes, but is not limited to: • Review of on-site service delivery The City of Miami Beach Instructor Monitoring Tool will be used to guide monitoring visits. A copy is attached as Exhibit D. Monitoring visits will take place throughout the year and will be done the by Program Coordinator of Morning All Stars. Promotion & Public Relations Requirements The Contractor agrees to receive Morning All Stars Brochures and Morning All Stars Flyers and make them available to clients during all in-person client interactions. Training Requirements Instructors (those implementing the All Stars curriculum) will be required to complete the following trainings prior to service provision: City of Miami Beach-TANIA PEREZ Page 12 of 13 Miami Beach Morning All Stars Program I All Stars Core Online Training provided by Tanglewood Research,.Inc. While initial training expenses are covered by the City, the Contractor agrees to reimburse the City for the early departure (termination) of any trained staff member prior to this contract's termination on a pro-rated basis as follows: Training Cost Online All Stars Core Training T $300.00 City of Miami Beach-TANIA PEREZ Page 13 of 13 Miami Beach Morning All Stars Program s Morning All Stars -- Child Information Form The ChildreKsTrust Data Tracker # Child's* Last Name , First Name Middle Initial Mother's Last Name , First Name Middle Initial Father's Last Name , First Name Middle Initial ---- -------------------------------- ......-.. -- - - _..... _ Does child live with a legal guardian other than mother or father. ❑ Yes ❑ No If yes, Guardian's Last Name , First Name , Middle Initial Street Address* City ZIP Code* Parent/Guardian Primary Phone* 11 1 1 11 Email* (You may be contacted by The Children's Trust for quality improvement purposes) Child's Gender* ❑ Male ❑ Female Child's Date of Birth (mo/day/yr)* Child's Race*: ❑ American Indian or Alaskan ❑ Asian ❑ Black or African American ❑ Pacific Islander ❑ White ❑ Other, please specify Child's Ethnicity*: ❑ Hispanic ❑ Haitian ❑ Other, please specify Is Child Proficient in English?* ❑ Yes ❑ No Child's Country of Origin Other Language(s) Spoken in the Home* ❑ Spanish ❑ Haitian-Creole ❑ Other ❑ None Miami-Dade County Public School ID#* ❑ No MDCPS ID ❑ Prefer not to give Last 4 Digits ONLY of Child's Social Security#* ❑ No SSN ❑ Prefer not to give Child's Current Grade* Child's Current School* Does Child Have Health Insurance (ex., private insurance, KidCare, Medicaid)?* ❑ Yes ❑ No (If not, we may be able to help you find affordable coverage-call 211 or visit www.thechildrenstrust.org) Does Child Have a Documented Disability?* ❑ Yes ❑ No If yes, do you have (check all that apply) ❑ an Individualized Family Service Plan (IFSP; if under 3) ❑ a diagnosis by a state certified/licensed professional ❑ an Individualized Education Plan (IEP) at school system . (ex., psychologist) ❑ a Section 504 Plan ❑ disclosure by the parent or guardian describing the ❑ a medical diagnosis from a doctor child's specific condition and/or need for accommodations If yes, how would you best classify the disability type(s)? (check all that apply)* ❑ Autism Spectrum Disorders ❑ Hearing Impairment (or deaf) ❑ Speech/Language Impairment ❑ Chronic Medical Condition ❑ Intellectual Disability (or MR) ❑ Visual Impairment (or blind) ❑ Developmental Delay (if under 5) ❑ Learning Disability ❑ Other Disability ❑ Emotional/Behavioral Disorder ❑ Physical Disability I give my permission for this information to be submitted to The Children's Trust for program monitoring and_evaluation purposes. The Children's Trust provi-des-funding for-,the„program. - - - PARENT/GUARDIAN SIGNATURE* DATE* For Staff Use Only (MUST BE COMPLETED) ORGANIZATION*CITY OF MIAMI BEACH SITE LOCATION*Nautilus Middle School-- *Required fields "" 16 Revised 08/01/11 The ChildrensTrust AUTHORIZATION FOR PHOTOGRAPHY/VIDEO I, the parent or guardian of hereby authorize and give consent to service providers and the staff of The Children's Trust of Miami-Dade County as follows: I hereby: 0 consent and authorize or C3 do not consent and authorize the staff of The Children's Trust of Miami-Dade County to take/use still photographs, digital photographs, motion pictures, television transmission, and/or videotaped recordings (hereinafter "Recordings") of me, my children, or my wards for educational, research, documentary, and public relations purposes. Signature of Parent or Guardian Signature of Witness - Date Date Any such Recordings may reveal your identity through the image itself without any compensation to you, your children or wards. Any and all Recordings taken of you, your children or wards shall be the sole property of The Children's Trust. With regard to the use of any Recordings taken of you, your children or wards, you hereby waive any and all present and future claims you may have against The Children's Trust of Miami-Dade County, their staff, service providers, employees, agents, affiliates and Board members. 3150 SW 3rd Avenue,.8th Floor • Miami, FL 33129 (305) 571-5700 • Fax: (305) 860-2328 www.thechildrenstrust.org MIAMI BEACH MORNING ALL STARS PARENTAL CONSENT & INFORMATION RELEASE AS THE PARENT AND/OR LEGAL GUARDIAN OF , I HEREBY PROVIDE CONSENT FOR MY CHILD TO PARTICIPATE IN MORNING ALL STARS SPONSORED BY THE CITY OF MIAMI BEACH OFFICE OF COMMUNITY SERVICES, MIAMI-DADE COUNTY PUBLIC SCHOOLS AND THE CHILDREN'S TRUST. BY PROVIDING CONSENT, I AGREE TO THE FOLLOWING: 1. RELEASE OF SCHOOL ACADEMIC, ATTENDANCE, AND BEHAVIORAL RECORDS TO PROGRAM STAFF. 2. MY CHILD'S PARTICIPATION IN YOUTH DEVELOPMENT GROUPS PROVIDED BY THE OFFICE OF COMMUNITY SERVICES ON: o MONDAY&WEDNESDAYS FROM 4:00 PM—4:45 PM BEGINNING NOVEMBER 5T"— DECEMBER 19T" 3. THE MORNING ALL STARS DISCIPLINE &ATTENDANCE AGREEMENT I RESERVE THE RIGHT TO TERMINATE MY CHILD'S PARTICIPATION AT ANY TIME AS WELL AS WITHDRAW CONSENT FOR RELEASE OF INFORMATION VIA WRITTEN NOTIFICATION TO THE OFFICE OF COMMUNITY SERVICES. THIS PARENTAL CONSENT AND INFORMATION IS VALID FOR ONE YEAR. PARENT/GUARDIAN NAME (PLEASEPRiNT) STAFF NAME(PLEASEPRiNT) PARENT/GUARDIAN SIGNATURE STAFF SIGNATURE DATE DATE The City of Miami Beach Ali Stars is funded by The Children's Trust.The Children's Trust is a dedicated source of revenue established by The ChildrensTrust voter referendum to improve the lives of children and families in 8ec=e All Children Am Our Children Miami-Dade County. i AAI AM MORNING ALL STARS DISCIPLINE AND ATTENDANCE AGREEMENT DISCIPLINE POLICY: IT IS UNDERSTOOD THAT IF ANY ONE OR MORE OF THE FOLLOWING ACTIONS FROM THE DISCIPLINE POLICY IS DISPLAYED BY THE CHILD IN MORNING ALL STARS, HE/SHE WILL BE SUBJECT TO LOSS OF PRIVILEGES THAT DAY. IF INAPPROPRIATE BEHAVIOR PERSISTS,THE CHILD'S PARTICIPATION IN THE PROGRAM CAN BE TERMINATED. CORPORAL PUNISHMENT OR ABUSIVE LANGUAGE OF ANY KIND IS NOT ALLOWED IN THE PROGRAM. RULES WILL BE CONSISTENT, BASED ON THE UNDERSTANDING OF INDIVIDUAL NEEDS AND DEVELOPMENT AND WILL PROMOTE SELF- DISCIPLINE AND ACCEPTABLE BEHAVIOR. POSITIVE REINFORCEMENT WILL BE USED TO GUIDE THE CHILDREN. IF A DISCIPLINE PROBLEM ARISES AND IS PERSISTENT, PARENTS AND THE PROGRAM COORDINATOR WILL WORK TOGETHER TO RESOLVE THE CONFLICT. IN AN EFFORT TO ENSURE THE PROPER HANDLING OF DISCIPLINE PROBLEMS AND CORRECTIVE DISCIPLINE PROCEDURES FOR CERTAIN SITUATIONS,THE FOLLOWING GUIDELINES HAVE BEEN ESTABLISHED: MINOR OFFENSES MAJOR OFFENSES TALKING BACK TO STAFF FIGHTING/PUSHING/KICKING NOT LISTENING TO DIRECTIONS GOING TO UNAUTHORIZED AREAS ANTAGONIZING/STARTING TROUBLE THROWING RESTRICTIVE OBJECTS/ENDANGERING THE PICKING/PLAY FIGHTING/WRESTLING SAFETY OF OTHERS.(STICKS, ROCKS,BALLS, ETC.) GOING INTO OTHER PEOPLE'S BELONGINGS DESTROYING ALL STARS EQUIPMENT OR PROPERTY NAME CALLING/TEASING DESTROYING MDCPS PROPERTY BEING DISRUPTIVE FOULLANGUAGE THE CORRECTIVE PROCEDURE ARE AS FOLLOWS: MINOR OFFENSES MAJOR OFFENSES ORAL WARNING 1 ST WRITTEN WARNING 1 ST LOSS OF PRIVILEGE 2ND PARENT CONFERENCE 2ND WRITTEN WARNING 3RD 1-DAY SUSPENSION 3RD PARENT CONFERENCE 4T"EXPULSION FROM PROGRAM 4T"1 DAY SUSPENSION ATTENDANCE POLICY: MORNING ALL STARS HAS A LIMITED CAPACITY AND IS ONLY AVAILABLE FOR STUDENTS WHO WANT TO PARTICIPATE IN THE PROGRAM.THEREFORE, STUDENTS ABSENT FOR 2 DAYS WILL BE TERMINATED FROM THE PROGRAM. PARTICIPANT NAME PARTICIPANT SIGNATURE DATE The City of Miami Beach All Stars is fi funded by The Children's Trust.The Children's Trust is a dedicated source of revenue established by The Childrerl'sTrWt voter referendum to improve the lives - .,r,;:,;:w.; ,T of children and families in 6eemse Ali Ch4dren Are Otr Childr" Miami-Dade County. MIAMI BEACH MORNING ALL STARS PICK UP/DROP OFF CONSENT FORM AS THE PARENT AND/OR LEGAL GUARDIAN OF , I HEREBY PROVIDE CONSENT FOR MY CHILD TO(PLEASE CHECK ONE : • ACCEPT TRANSPORTATION PROVIDED BY THE CITY OF MIAMI BEACH OFFICE OF COMMUNITY SERVICES TO OR FROM THE FOLLOWING LOCATION: f ` *ADDRESS CHANGES MUST BE MADE AT LEAST ONE WEEK IN ADVANCE. • BE DROPPED OFF BY A TRUSTED ADULT BY 8:00 A.M. (MORNING SESSIONS ONLY) o WALK HOME OR TAKE PUBLIC TRANSPORTATION HOME WHEN THE PROGRAM ENDS AT 4:45 PM. (AFTERNOON SESSIONS ONLY) o GET PICKED UP BY A TRUSTED ADULT WHEN PROGRAM ENDS AT 4:45 PM*. AFTERNOON SESSIONS ONLY *I UNDERSTAND THAT THERE WILL BE NO ADULT SUPERVISION AFTER 4:45-PM. PARENT/GUARDIAN NAME (PLEASEPRINT) STAFF NAME (PLEASE PRINT) PARENT/GUARDIAN SIGNATURE STAFF SIGNATURE DATE DATE The City of Miami Beach All Stars is funded by The Children's Trust.The Children's Trust is a dedicated source of revenue established by The Children'sTmst voter referendum to improve the lives of children and families in Because All 00dren are ow chiidm Miami-Dade County. MIAMI BEACH MORNING ALL STARS EMERGENCY CARE AUTHORIZATION Name of Child: Date of Birth: Guardian Name: Phone#: In case of an emergency, I authorize the following people to provide permission for care for my child in the event that I am unavailable or cannot be reached: Name: Relationship: Phone#: Name: Relationship: Phone#: Does your child have Medical Health Insurance? ❑ Yes ❑No If yes, please provide the following information: Company: Policy#: Group#: Policy Holder: Name of Primary Care Physician: Phone#: Student is taking the current medication(s): List any information All Stars needs to be aware of regarding your child I authorize the Morning All Star Program staff to contact emergency services to provide care for my child in a life threatening emergency prior to contacting me: ❑ Yes, I Give Consent ❑ No Consent Parent Signature Date The City of Miami Beach All Stars is n funded by The Children's Trust.The Children's Trust is a dedicated source of revenue established by The ChildreKsTmst voter referendum to improve the lives of children and families in Because All Children Are Our ChMren Miami-Dade County. Notice of Privac y Practice This notice describes how your personal information may be used and disclosed and how you can get access to this information. Please review it carefully. Our commitment to your privacy The City of Miami Beach and The Children's Trust are dedicated to maintaining the privacy of your personal information as part of providing professional service. We also are required by law to keep your information as a requirement of providing professional care. We also are required by law to keep your information private. These laws are complicated, but we must give you this important information. This pamphlet is a shorter version of the full, legally required Notice of Privacy Practice (NPP)and you may have a copy of this to read and refer to for more information. However, we can't cover all possible situations so please talk to our Privacy Officer(see the end of this pamphlet)about any questions or problems. We will use the information you provide to enable you to access services and other social service operations. After you have read this NPP, we will ask you to sign a Consent Form to let us use and share you and/or your child's information. If you do not consent or sign this form, we are unable to provide services to you and/or child. If the City of Miami Beach, The Children's Trust or you want to use or disclose(send, share, release) your information for any other purposes, we will discuss this with you and ask you to sign an Authorization form to allow this. We will safeguard your information but there times when the law requires us to use or share it in order to access needed services. For example: • When there is a serious threat to your health and safety or the health and safety of another individual or the general public. We will only share information with a person or organization that is able to help prevent or reduce the threat. • If compelled to do so by court order. • For federal, state or local entitlement programs. There are some other situations like these but which don't happen very often. They are described in the longer version of the NPP. Your rights regarding your personal Information You can ask us to communicate with you about your personal and related issues in a particular way or at a certain place which is more private for you. For example, you can ask us to call you at home-and not at work, to schedule or cancel an appointment. We will try our best to do as you ask. You have the right to ask us to limit what we tell people involved in your care, such as provider or others and friends. x You have the right to a copy of this notice. If we change this NPP, we will post the new version in our waiting area and you can always get a copy of the NPP from our office. • You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with the Privacy Officer and with the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the care we provide to you in any way. If you have any questions regarding this notice or our information privacy policy. Please contact our Privacy Officer who is Marcela Rubio and can be reached by phone at 305-673-7000 ext. 2020 by e-mail at marcelarubio(&-miamibeacfl.gov. The effective date of this notice is Parent/Guardians Signature: AAIAMIIBEACH Morning All Stars Program Agency Referral Out Form Parent Name Name of child enrolled Address/Zip Code Contact Number Legal Status ❑ US Citizen ❑ US Resident ❑ Status Pending Primary Language Race/Ethnicity ❑ English ❑ Spanish ❑ Creole ❑ Other ❑White, Non-Hispanic ❑ Hispanic ❑ Black, Non-Hispanic ❑ Other Marital Status Housing ❑ Single ❑ Divorced ❑ Domestic Partnership Status ❑ Rent ❑ Homeless ❑ ❑ Married ❑ Separated ❑ Other ❑ Own ❑ Live w/others Other 1. Are there any children under the age of three in your household? 2. Do any of your children have difficulty attending school regularly? 3. Would you like the City of Miami Beach to contact you regarding any of the following services? ❑Counseling services ❑Medicaid/Medicare Assistance ❑Day Care/Child Care F1 Supplemental Nutrition Assistance Program ❑Adult Day Care (Formerly Food Stamps) ❑Educational Services ❑Survivor's Benefits ❑ Elder Services ❑Temporary Assistance for Needy Families ❑ Employment Services ❑Transportation Services ❑Home Care Assistance , ❑Unemployment Compensation ❑Housing Assistance ❑Utility Assistance ❑Legal Services Assistance ❑Vocational Training 4. Are there any other services or benefits that you would like The City of Miami Beach to assist you with? I understand that this release authorizes an exchange of information between the City of Miami Beach Office of Community Services and community-based agencies in order to provide me and/or my child(ren)with the most complete and thorough services available. It does not authorize release to any other person or agency except those to which I am being referred for services. Unless revoked in writing, this release shall remain in force for a period of 24 months from the date of authorization. My signature below indicates that I have been informed of and understand the eligibility information provided within this form and certify that it is true and correct and subject to verification.Any false or misleading responses or submissions on my part may lead to the refusal of services. Client Authorization Staff Signature Date e_ MIAMI BEACH } The sTrust Morning All Stars,Referral Form is.being referred to Morning All Stars by School Administration, Parent/ Guardian based on the following criteria: ❑ Disciplinary issues at school ❑ Involvement with the Department of Juvenile Justice ❑ Involved in or associating with others involved in other high risk activities such as smoking, drinking, using illegal drugs, participating in sexual acts, fighting, bullying and/or delinquency Print Name Relationship to student Date i CV L; 0 0 0 0 0 0 0 Z Z Z Z Z Z Z sy �✓c� • • 8 a O 1 • E ► LU CD N • • L C U) 0 1 G ! Q s L 0 + 1 • • O N / = s � 1 • s , + • • 9 E 9! • • ► • • tl 9 • • ® m m 1 • 1 • 1 1 • 1 • m ® ° s + • Af • • s ;y = ji v}i � � • tl t +� s ._ j' 's' O ° 1 m� • ► sx4fL'im�� c m • L *-0 �f/^� ss y s' e e • '% �.: c Vw ei yyN S g ® • � , Q Q r+ y,—•� F- ..