| COMMON AGENDA
|| GCC exists to connect people and organizations and empower everyone to support the children and families in our communities. Our goal is to maximize the potential that lies within everyone so that families and
communities can thrive! (Birth-Rocker)
|PURPOSE|| Partners working collectively to build on the wellbeing of all individuals
and families in our communities.
|COMMUNITY GOALS|| As a result of our data from Source for Siouxland we have formed focus groups on Health, Safety, Education, Economic stability, and Quality of life to determine new goals, using data and community information. You are
always welcome to be a part of any group!
|COLLECTIVE IMPACT|| Common Agenda
Mutually Reinforcing Activities
Shared Measurement Systems
|AREAS OF IMPACT|| Economic Stability
Quality of Life
|WE BELIEVE|| Growing Community Connections believes that strengthening our
community requires all of us working together.
-Maintaining open communication with our partners and the community
-Identifying community strengths and needs
-Actively coordinating and sharing lessons learned
-Defining common outcomes
-Aligning individual community needs and resources to meet those outcomes
-Seeking additional resources to help reach our goals
-Using evaluation and community data to strengthen our programs
| DIVERSITY, EQUITY,
| -GCC endeavors to build belonging in every meeting.
-GCC is a Tri-state collaborative that strives to connect and support our wonderfully diverse communities.
We strive to facilitate a culture where diversity, equity, and inclusion are respected and intentionally valued by implementing thoughtful, practical, consistent, and innovative strategies that can serve as a model for those in our communities.
-GCC denounces discrimination and opposes any form of oppression.
-We strive to improve the quality of life for all individuals in the Siouxland area including diverse cultures, backgrounds, and perspectives.
-GCC is committed to supporting the work of community partners who strive to build positive protective factors for our youth and children and preventative supports that keep families together.
-We are a data-driven collaboration providing evidence that we are meeting the needs of our diverse community.
Community Response Team
Other Service Providers/Informal Support
Dakota County Community Response
115 E 28th Street
S Sioux City, NE 68776
CLIENT RELEASE OF INFORMATION
I, _________________________________, authorize the release of my information to Dakota County Community Response and their affiliated partner agencies & Coaches.
The below list is not all inclusive. Based on client needs, Dakota County Community Response and its agents/coaches may determine that information may need to be released to other organizations for the purpose of completing tasks or activities that the client may have requested or initiated with their application for assistance.
Partner Agencies: Center for Siouxland, City of South Sioux City, Equus Workforce Solutions, Heartland Counseling Services, Immigrant Legal Center, Nebraska DHHS, Nebraska Legal Aid, NENCAP, Siouxland Community Health Center, South Sioux City Housing Agency, South Sioux City Schools, Unity in Action
I, _____________________________________ hereby authorize the reciprocal release of information contained in these records between Dakota County Community Response and its partnering agencies.
The purpose for such disclosure is: Assessment, services, and case management for connections to community resources.
WAIVER & RISK AGREEMENT
I, _________________________________, do hereby affirm and acknowledge that I am responsible to be aware of the risks associated with accessing available programs/trainings/financial support provided by Dakota County Community Response, including damage to property belonging to me or to others, injury, illness, or other unforeseen circumstances to myself or others, whether caused by me or by others or by conditions/circumstances within or outside of my control or the control of others. I understand an exhaustive description of potential hazards and risks associated with such activity(ies) is not possible and that unknown or unanticipated hazards or risks may result in injury, illness, or death. If equipment is involved in such activity (ies), I agree to inspect all such equipment before use, ask questions if I do not fully understand how to us and/or operate the equipment, accept all equipment “as is”, and to return all equipment before use that is believed to be damaged or defective.
In consideration of my being provided the opportunity to participate in such activity (ies), I fully and completely assume all hazards and risks associated with such activity (ies) and by signing this Waiver and Risk Agreement, do hereby forever waive any responsibility or liability on the part of and completely release Dakota County Community Response, and its officers, directors, members, employees and agents from any and all claims or liability or damage, known and unknown, now and hereafter existing in connection with my participation in any form whatsoever in such activity (ies).
I have read the foregoing Waiver and Risk Agreement. I fully understand the terms and that I may have given up legal rights by signing this document. I sign it freely and voluntarily with the intent to be bound to the terms of this document. My agreement is binding on me and my heirs, estate, and any other parties who may be able to assert a claim by or through me.
HIPAA DISCLOSURE & RELEASE
I, _______________________________, authorize and understand that I have been made aware of Dakota County Community Response HIPAA privacy practices. As Dakota County Community Response operates in the state of Nebraska, the Department of Health & Human Services (DHHS) monitors HIPAA disclosure for the purpose of rendering & engaging in services. My signature on this form grants access and disclosure to my own personal or children’s PHI (Protected Health Information) for the purpose of completing or rendering services via Dakota County Community Response.
Dakota County Community Response, and its officers, directors, members, employees and agents will be allowed to access my or my children’s PHI at any time after signature of this Release for the purpose of completing my request/application and services based on the application that I submit.
My HIPAA authorization can be revoked at any time by notifying Dakota County Community Response in writing at the above listed address. If I revoke my authorization before services have concluded, Dakota County Community Response may terminate my services due to lack of information or ability to disclose PHI to its officers, directors, members, employees, and agents.
By signing below, I understand that I must complete the Community Response Exit Survey. If I do not complete the survey, I may not be able to receive any further assistance from Dakota County Community Response funding. The Community Response Exit Survey will be provided to you at the anticipated last coaching visit and/or within 30‐90 days of enrollment into Community Response.
I have read the foregoing Waiver and Risk Agreement, Client Release of Information & HIPAA Disclosure & Release. I fully understand the terms and that I may have given up legal rights by signing this document. I sign it freely and voluntarily with the intent to be bound to the terms of this document. My agreement is binding on me and my heirs, estate, and any other parties who may be able to assert a claim by or through me.
|Signature of Adult Participant||Name of Adult Participant (printed)||Date|