Sibling Connections Application Page

We appreciate you taking the time to complete this information for your sibling group. After you complete this brief registration/contact information form, you will have an opportunity to enter your own contact information to create an account, as well as adding the other siblings in this sibling group to our database. The consent/authorizations should be completed by an authorized party (legal guardian, DHS representative, etc.). A digital copy of the consent/authorizations is available by emailing: crystala@elevatingconnections.org. Once you have completed these steps, you will be contacted by our Sibling Connections' Program Coordinator in order to get more information about both the sibling group, and the child/youth individually to ensure that our program will meet their needs. Please contact crystala@elevatingconnections.org if you have any questions or issues registering.

Contact Information Form

Child First Name:

* Required

Child Last Name:

* Required

Birth Date:

* Required

Gender, how does child identify:.

* Required

Pronouns:

* Required

Ethnicity:

* Required

Is there currently an open Dependency & Neglect case?

* Required

How can we best support this sibling group as a whole & individually?

* Required

How often do the siblings have in person visits? Where do they take place?

* Required

I understand that I, or an emergency contact, will be called in the event of any major illness or injury and a report will accompany the child home and/or to a caseworker concerning any major or minor illness, injury or incident of concern. If this child needs immediate attention and there is not time to contact me or the emergency contact, I authorize any staff, counselors, or volunteers of ELEVATING CONNECTIONS and/or any medical clinic, hospital or emergency facility to administer all medicines, prescription drugs and other medical remedies required for, or on behalf of, this child while said child is in attendance and participating at any of the functions or facilities of ELEVATING CONNECTIONS. I further warrant that I have the authority to grant this medical authorization on behalf of this child and agree to hold ELEVATING CONNECTIONS and/or medical clinic, hospital or emergency facility harmless by reason of my executing this medical authorization.

Consent to receive medical treatment:

* Required

Consent for medical treatment Date:

* Required

I understand that pictures and videos will be taken at ELEVATING CONNECTIONS' events for use on social media and marketing purposes. By agreeing, you are allowing the child/youth's likeness to be used for these purposes, with the understanding that no identifying pictures or other identifying information of any kind will be shared without prior authorization from the legal guardian.

Media Agreement Consent :

* Required

Media Agreement Date:

* Required

Legal Guardian Name

* Required

Legal Guardian Email

Legal Guardian Phone

* Required

Please leave this checkbox blank