Tania Perez PSA - City's Morning All Stars Program 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, 2013, 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 Avenue, 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 Forty-Four (144) youth and their families in accordance with The
Morning All Stars Program Grant, dated August 1, 2013. 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
Twenty-Five Dollars ($25.00) per each hour worked for Six (6) hours a week for Fifty
(50) weeks, for a maximum not to exceed Seven Thousand Five Hundred Dollars
($7,500).
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 Seven
Thousand Five Hundred Dollars ($7,500).
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.
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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, 2014.
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, 2014.
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.
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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
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Miami Beach Morning All Stars Program
CONSULTANT PURSUANT TO ITS PROVISION OF THE SERVICES
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
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Miami Beach Morning All Stars Program
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shall be valid unless amended in writing, signed by the parties hereto, and
approved by the City.
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
perpetuity to the City, for public use.
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
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Miami Beach Morning All Stars Program
program coordinator designated by the City Manager, who shall be Office of
Community Services, Division Director. The Contractor's project manager shall be
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 Avenue
Miami Beach, FL 33141
(786) 443-0767
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.
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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.
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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:
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By:
Cit Clerk ity Ma alter
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Date
INCORP ORATED:
FOR CONTRACTOR: .-.•
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ATTEST:
By: By:
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Witness Sig ture
Tania Perez nn)
Witness Printed NAme
$ 21
Date Date
APPROVED AS TO
FORM & LANGUAGE
&FOR EXECUTION
4A
City Att me Date
City of Miami Beach-TANIA PEREZ P9 of 13
Miami Beach Morning All Stars Program
EXHIBIT "A"
"SCOPE OF SERVICES"
The Contractor agrees to provide the following services to youth referred to the
Morning All Stars Program:
Service Units of 1 Documentation of
Service
Intake & Consent Forms 144 Assist with Completion and execution of the
following documents:
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• The Children's Trust Child Information Form
• The Children's Trust Photography/Video
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
Emergency Care Authorization Form
■ City of Miami Beach Morning All Stars Program
Discipline and Attendance Agreement
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■ City of Miami Beach Morning All Stars Program
1 Pick Up/Drop Off Consent Form
■ City of Miami Beach Morning All Stars program i
Referral Out Form
Recruitment and Referral of 144 Distribution and/or completion of the following
Participants documents:
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■ 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
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Instructor 91 j Implement All Stars curriculum to various cohorts,
including supplemental sessions throughout the
2013-2014 contract 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
City of Miami Beach-TANIA PEREZ Page 10 of 13
Miami Beach Morning All Stars Program
attached as Exhibit B.
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$ervice .'.Service Location Tirneframe
Intake & Consent 144 School and City Upon consent of client
Forms Facility
Recruitment and 144 School and City Upon identification of
Referral of Participants Facility need
Instructor 91 School and City Approximately 13
Facility session x 7 cohorts
throughout the 2013-
2014 contract year
Service Benchmarks
Service 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 1 1 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
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:
Cost
Training
Online All Stars Core Training $300.00
Online All stars Booster Training $300.00 !
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City of Miami Beach-TANIA PEREZ Page 13 of 13
Miami Beach Morning All Stars Program
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1�xhibit
ALL STARS PROGRAM
The ChildrensTrust
.:...::...:........... ...: :..:......:. .... ; CHILD INFORMATION FORM (SAMIS)
Child's Last Name First Middle
Child's Date of Birth (mo/day/yr) Child's Gender ❑ Male ❑ Female
Last 4 Digits ONLY of Child's Social Security# ❑ No SSN ❑ Prefer not to give
(Miami-Dade County Public School ID# ❑ No MDCPS ID ❑ Prefer not to give
Child's Current School
Is Child Proficient in English.? ❑ Yes ❑ No
Other Language(s) Spoken in the Home ❑ Spanish ❑ Haitian-Creole ❑ Other ❑ None
Street Address City ZIP Code
Child's Ethnicity ❑ Hispanic ❑ Haitian ❑ Other, please specify
Child's Race ❑ American Indian or Alaskan ❑ Asian ❑ Black or African American
❑ Pacific Islander ❑ White ❑ Other, specify
Child's Current Grade
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)
Child's Primary Caregiver (full name)
Primary Caregiver Email
Primary Phone
You may be contacted by The Children's Trust for quality improvement purposes)
Number of Children Living in the Household (including child participant)
Is the Participant a Child of a Military Family? ❑ Yes ❑ No
A member of the child's family is either: 1) an active duty member of the uniformed services; 2) a
member of the National Guard,or reserves; 3) a member or veteran who was severely injured and
medically discharged or retired; or 4) a member killed in the line of duty.
Continue to Next Page
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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)
❑ an Individualized Education Plan (IEP) at school system
❑ a Section 504 Plan
❑ a medical diagnosis from a doctor
❑ a diagnosis by a state certified/licensed professional (ex., psychologist)
❑ disclosure by the parent or guardian describing the 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 ❑ Learning Disability
❑ Chronic Medical Condition ❑ Physical Disability
❑ Developmental Delay (if under 5) ❑ Speech/Language Impairment
❑ Emotional/Behavioral Disorder ❑ Visual Impairment (or blind)
❑ Hearing Impairment (or deaf) ❑ Other Disability
❑ Intellectual Disability (or MR)
If you are interested in other services funded by The Children's Trust,
please call 211 or visit www.thechildrenstrust.org
I give my permission for this information to be submitted to The Children's Trust for program
monitoring and evaluation pu-rposes. The Children's Trust provides funding for the program.
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PARENT/GUARDIAN SIGNATURE DATE
FOR STAFF USE ONLY (MUST BE COMPLETED)
ORGANIZATION: City of Miami Beach
SITE LOCATION:
PRIORITY POPULATION MEMBERSHIP (check all that apply):
❑ Migr Farm Wrk ❑Dep Syst ❑Delin Syst
Revised 08/12
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1 � iM BE-I CHI
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The Childrer'sTrust
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:
13-consent and authorize or, 13 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, 8t" Floor • Miami, FL 33129
(305) 571-5700 • Fax: (305) 860-2328
www.thechildrenstrust.org
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All Stars Program
Parental Consent & Information Release
As the parent and / or legal guardian of I hereby
provide consent for my child to participate in the All Stars Program 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 (please check one):
• Tuesdays from 8:00 am — 8:45 am beginning January 8th - April 9th.
o Tuesdays from 8:00 am — 8:45 am beginning January 10th - April 11th.
• Monday & Wednesdays from 4:00 pm — 4:45 pm beginning January 14th � March 6th.
3. The All Stars Program 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 (please print) 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 Childmi sTrust voter referendum to improve the lives
of children and families in
Bec=e All quldren Are OtaChildren Miami-Dade County.
All Stars Program
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 the All Stars Program, 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 Foul language
Antagonizing /starting trouble Going to unauthorized areas
Picking / play fighting /wrestling Throwing restrictive objects / endangering the
Going into other people's belongings safety of others. (Sticks, rocks, balls, etc.)
Name calling /teasing Destroying All Stars equipment or property
Being disruptive Destroying MDCPS property
The corrective procedures are as follows:
Minor Offenses Maior Offenses
Oral Warning 1St Written Warning
1St Loss of privilege 2nd Parent Conference
2nd Written warning 3r1 1-Day Suspension
3rd Parent Conference 4th Expulsion from Program
4th 1 day suspension
ATTENDANCE POLICY: The All Stars Program 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
The City of Miami Beach All Stars is
funded by The Children's Trust.The
Participant signature Children's Trust is a dedicated source o
revenue established by voter
The Childr InSTr jSt referendum to improve the lives of
_ children and families in
aecaue All Gh ldtwi"Are Our Children Miami-Dade County.
Date
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All Stars Program
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:
*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)
• walk home or take public transportation home when the program ends at 4:45 pm. (afternoon
sessions only)
• 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 (please print) 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 ChildrensTrust voter referendum to improve the lives
of children and families in
kc=e All Children Are Cur Children Miami-Dade County.
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Morning All Stars Program
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 Pediatrician/Primary Care Physician:
Phone#:
Student is taking the current medication:
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 Children'sTrust
Notice Of Privacy 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.
S
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(,U-)miamibeacfl.gov.
The effective date of this notice is
Parent/Guardians Signature:
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All Stars Program Referral Form
is being referred to the All Stars Program
by Parent/ Guardian or School Administration based on the following
criteria:
❑ Concerned that child may be exposed to or Involved in or associating
with others involved in high risk activities such as smoking, drinking,
using illegal drugs, participating in sexual acts, fighting, bullying and/or
delinquency
❑ Disciplinary issues at school
❑ Involvement with the Department of Juvenile Justice
Print Name
Signature
Relationship to student
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 ChildreKsTrus# voter referendum to improve the
lives of children and families in
Miami-Dade County.
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