Have you thought about this?  What does my staff need to know in order to run a safe program?  What information do we need to harvest from our members to be able to access emergency information?

There are two schools regarding this issue.  First, if you don’t have any information, you may not be liable.  There is a club that runs in the middle of our state.  These are good folks wanting to do good things for the mentally challenged community.  They don’t have any information about the people they bring together for entertainment.

Second, gather as much information as you believe owill be enable you to run a safe program.  At Special Gathering, we worked with many nurses and social workers (support coordinators) to be able to determine what we needed.  These are the things we were told by many professionals that would be needed.

  1. Name of the members
  2. Address, City, State and Zip code
  3. e-mail address of closest relative or staff
  4. main phone number
  5. Date of birth
  6. Name of closest relative
  7. Address, city, state and zip of closest relative
  8. Home, work, cell and any other phone number
  9. Persons to notify in case of emergency (other than closest relative)
  10. Home, work, cell and other phone numbers of emergency person
  11. Name, phone number of support coordinator
  12. Information regarding the person competency status.  (This is a confusing area.  The best question to ask is:  Have you been adjudicated incompetent by a court of  law?
  13. Name and phone numbe rof guardian
  14. List of chronic medical conditions.  Also, a list of procedures necessary if the condition worsens while at Special Gatheirng
  15. Does the person have seizures
  16. List all allergies
  17. List all medications.

Additionally, because of HIPPA Law, we ask that a Consent to Release Confidential Information form be filled out.  This form includes:

  1. Individual’s name
  2. Date of Birth

Statement to support coordinator:  I do hereby authorize the Agency for Person with Disabilities or its representatives to release the information check below from my records, or those of my child, or the individual for whom I am legal guardian.

In the form have these items pre-checked:

For Healthy and Safety

  1. Medications
  2. Allergies
  3. Emergency contacts
  4. Seizure activity
  5. Emergency contact information
  6. Notification of adjudication of incompetency
  7. Notification of change of Support Coordinator (or social worker).

For Pastoral Care

  1. Notification of Hospitalization
  2. Notification of Death in the family
  3. Notification of other sadness

Include name and address of ministry staff who will be responsible for recording this information.  Signatures should include:

  1. Signature of individual
  2. Signature of parent/guardian
  3. Signature of witness (if signed iwth a mark)

The third form is a Support Coordinator Release letter  It should look like this:

Dear (The name of the person’s support coordinator should be put on a line and will need to be  explained on the form)

I am a member of The Special Gathering.  I would like The Special Gathering to be kept up to date with any health concerns that may be needed in an emergency, such as midicine I take and allergies I have.

I would also like The Special Gatheirng to be notified in case I need pastoral care.  If I am sich or hospitalized, if there is a death of a joved one or of other sadness.

The Special Gathering worked with two support coordinators in desinging this release form, but if you have one you would rather use, please bring it to me to sign.

I would also request that you reissue this release form every year at my support form.

Sincerely,

________________                                  _________________________________

Member signature                                        Parent of guardian sign

Date                                                                     Date

The fourth form is a simple statement signed by the member what states that they do not want to give any information to Special Gathering.

Except for a member’s salvation, there are few things that are more important than the safety of our members.  As our executive director, Richard Stimson said, “We cannot survive a breach of confidence within the community.”  God blesses those who are wise enough to prepare for the harsh weather

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