Hotel Signature Form

City of Dallas ESG Program: Confidentiality/Release of Information
Applicant 1 Name:*
First Last
Applicant 2 Name (if applicable):
First Last
Applicant Address:*
Street Address Address Line 2 City State ZIP Code
Applicant County:*
Preferred Phone:*
Alternate Phone:
Email 1:*
Email 2:
Statement of Confidentiality
It is the policy of the Program to treat your records as confidential and not disclose them, without your written authorization, subject to certain disclosures that are permitted or required by law. This means that confidential information will not be disclosed (even to family or household members) without your authorization. In an effort, though, to provide all the services for which you are eligible, it is necessary that we have your authorization to release information to other participating agencies/entities/persons involved in providing Program services to you. This information may be entered into a computer database that other social service agencies are able to access. Program services will be contingent on the Program’s ability to share information with these other agencies/entities/persons.
Authorization*
I understand that confidential information may be shared with other agencies/ entities/persons, and that such agencies/entities/persons may share confidential information with Family Gateway, for the purpose of providing program services.
Emergency/Alternate Contact
In the event of an emergency, or in the event that the Program is unable to contact me, I authorize the Program to contact the person below:
Emergency Contact Name:*
First Last
Emergency Contact Address:
Street Address Address Line 2 City State ZIP Code
Emergency Contact County:
Emergency Contact Phone 1:*
Emergency Contact Phone 2:
I authorize the Program service provider to contact me:*
- Select All
- By mail
- By preferred phone
- By leaving a message on my preferred phone answering machine
- By alternate phone
- By leaving a message on my alternate phone answering machine
- I authorize the Program service provider to identify itself by name.
Other instructions for program service provider, if applicable:
E-Signature Acknowledgment*
I understand that typing my name below and throughout this contract serves as a legally binding digital signature.
E-Signature of Applicant 1 (please type first & last name):*
E-Signature of Applicant 2 (please type first & last name) if applicable:
Date:*
MM slash DD slash YYYY
Request for Shelter Agreement
Acknowledgment of Receipt*
I have downloaded the full PDF packet and reviewed the Request for Shelter Agreement on page 3.
E-Signature of Applicant 1 (please type first & last name):*
E-Signature of Applicant 2 (please type first & last name):
Date:*
MM slash DD slash YYYY
Family Gateway Crisis Hotel Stay Program Statements of Understanding
The goal is to provide temporary emergency shelter to literally homeless families where no other shelter placement can be found until an emergency shelter is available.
Length of Program Participation*
I understand that the length of stay at the hotel is contingent upon the first available safe shelter and is used only for temporary emergency stay. I agree to transition to the first available safe shelter.
Confidentiality*
I understand that the location of the hotel is to remain confidential. I agree not to release the address, room number, and/or phone number to anyone without first discussing it with your case manager.
Please remember that all information will be kept confidential, including all personal information and all communications, observations, and information made by and between or about all residents, non-residents, employees, volunteers, student interns, and board members.
Records*
I understand that Family Gateway is required to keep records on all clients for your benefit as well as for our own accountability. These records are confidential and are the property of Family Gateway and must remain here. Your own record is open for your inspection and comments. If you wish to look at your record, you must set up an appointment with the Family Gateway Center Director. Your record will document your need for services, your goals and plans, and a description of the services provided. Other client’s names will not appear in your file, nor will your name appear in any other client files. No one will be told that you are utilizing our services, and your situation will not be discussed with people outside of Family Gateway except in the following situations:
- A “Consent to Release Information” form is signed by the client, releasing information to a specific individual oragency.
- A valid and enforceable subpoena is presented to Family Gateway management.
- Child Abuse/ Elder Abuse/ Abuse of a disabled individual person will reported under state laws, as prescribed bythose laws.
- If there is a valid warrant out for your arrest Family Gateway is obligated to work with law enforcement officers.
- Knowledge or suspicion of being a danger to yourself or others.
Right to Refuse Services*
Services to an individual cannot be denied on the basis of race, color, sex, national origin, religion, age, physical or mental disability, including positive diagnoses of HIV/AIDS. Services can be refused at any time for any non-discriminatory reason including but not limited to: safety concerns, history of failure to comply with program policies and procedures, and untreated medical and/or mental health conditions that pose a risk to clients and/or staff.
Drug/Alcohol Policy*
I understand that the use of alcohol and/or drugs on the hotel premises is prohibited, including medical marijuana. The abuse and/or sale of prescription medication are also prohibited.
Health and Well Being*
I agree that while you are in the hotel program, you will do your best to provide a safe and healthy environment for yourself (and your children). My personal hygiene will be taken care of daily. I will allow the hotel housekeeping staff daily access to my room to maintain cleanliness.
Advocacy and Case Management*
I understand that I will be required to meet with the Crisis Housing Manager as scheduled and develop and follow a Case Plan.
Food*
In the event that you are in need of food while residing in the hotel, provisions will be made. Please discuss with the Crisis Housing Manager and they will assure that need is met.
Bus Passes*
On a need-based level, bus passes may be issued to clients only to and from Family Gateway and other community resources. This is a resource only to be used in circumstances where you are unable to afford public transportation and do not have a vehicle.
Grievance Procedures*
In keeping with the basic philosophy of Family Gateway and in the best interest of each client served, clients are afforded the opportunity to submit in writing any grievance or complaint alleging abuse, neglect, or exploitation. This procedure is also used to address complaints of alleged discrimination based on gender, age, religion, race, national origin, and shall include disability. Please ask the Crisis Housing Manager to obtain a grievance form.
Acknowledgment of Receipt*
I understand and agree that I have received and reviewed Family Gateway Crisis Hotel Program’s Statements of Understanding. I understand and agree that I must abide by all policies as described. If I have any additional questions or concerns I will speak with staff as soon as possible.
E-Signature of Guest 1 (please type first & last name):*
E-Signature of Guest 2 (please type first & last name) if applicable:
Date:*
MM slash DD slash YYYY
Family Rights & Responsibilities
Please download the full PDF packet and review the Family Rights & Responsibilities on pages 7-10. By signing below, you are agreeing to the rights and responsibilities in this packet.
E-Signature of Guest 1 (please type first & last name):*
E-Signature of Guest 2 (please type first & last name) if applicable:
Date:*
MM slash DD slash YYYY
Acknowledgment of Welcome Packet
By signing below, I acknowledge that I have received, read & understand the information included in the Welcome & Orientation Packet to the Annette G. Strauss Family Gateway Emergency Shelter. I agree to participate in the program through case management & vocational intervention, abide by the rules, follow schedules and perform responsibilities for successful involvement in the Family Gateway Program. Furthermore, I acknowledge that I may be asked to move out of the Family Gateway Emergency Shelter if, in fact, I do not abide by the conditions, information and rules stated therein.
E-Signature of Guest 1 (please type first & last name):*
E-Signature of Guest 2 (please type first & last name):
Date:*
MM slash DD slash YYYY
Acknowledgment of Orientation
By signing below, I acknowledge that I have attended orientation with Family Gateway staff.
E-Signature of Guest 1 (please type first & last name):*
E-Signature of Guest 2 (please type first & last name):
Date:*
MM slash DD slash YYYY
Hotel Guest Policies & Responsibilities
Hotel stays are reserved for those clients who are Literally Homeless in uninhabitable living situations, such as on the streets, abandoned buildings, cars or the like. As such, your family is being provided a temporary overnight stay in a hotel to serve as temporary overnight shelter. The following policies are to ensure a comfortable, safe temporary shelter for you and your family for tonight, and to re-evaluate your situation the next morning to find longer term accommodations. Please download the full packet and review the information on page 12.
Release of Liability
For and in consideration and temporary lodging for me and my family, I hereby release and discharge Family Gateway, its directors, officers, agents, employees, and volunteers from and all responsibility and liability for any injury, illness, or any claim of any sort whatsoever arising in connection with the care and maintenance of myself or my child(ren)or those that I am the Guardian over. In addition to this, Family Gateway has permission to transport me and /or any member of my family. I acknowledge that transportation involves an element of risk, but understand that all precautions will be taken to ensure the safety and health of my family and my child(ren), but I assume all risks and hazards incidental to such participation. I therefore release, absolve, indemnify, and agree to forever hold harmless Family Gateway, its insurers, employees/staff, interns, representatives, and its insurers, employees, and representatives, from any and all financial responsibility for any injury, illness, or death as a direct or indirect result of the transportation that is provided. By signing below, I acknowledge that I have read and understand the aforementioned information.
E-Signature of Guest 1 (please type first & last name):*
E-Signature of Guest 2 (please type first & last name):
Date:*
MM slash DD slash YYYY
Personal Possessions
The following are some quick references when you are planning to enter or leave Family Gateway: 1)Your room will be clean when you enter Family Gateway – it is expected itwill be clean EVERYDAY when you leave. This includes but is not limited to: a.Beds made if you are staying in your room for more than one night. b.Trash being taken out each morning before 10 AM. c.Diapers being taken to the OUTSIDE dumpster IMMEDIATELY fordisposal. d.Food and drinks, other than water to be consumed in the cafeteriaor lobby. e.Swept and mopped (see the front desk/janitors closet) 2)When you are checking out ALL items must be removed from your room.All items that are not will be disposed of by noon the same day and willNOT be replaced by Family Gateway or its staff I have read and understand the information provided in the document entitled Personal Possessions. I agree to abide fully according to the provisions, as stated.
E-Signature of Guest 1 (please type first & last name):*
E-Signature of Guest 2 (please type first & last name):
E-Signature of Guest 2 (please type first & last name):
Date:*
MM slash DD slash YYYY
Mandated Reporting of Suspected Child Abuse & Neglect
Under the Child Protective Services Act, mandated reporters are required to report any suspicion of abuse or neglect to the appropriate authorities. The employees of Family Gateway are considered mandated reporters, under this law. The employees of Family Gateway are not required to discuss their suspicions with parents prior to reporting the matter to the appropriate authorities, nor are they required to investigate the cause of any suspicious marks, behavior or condition prior to making a report. Under the Act, mandated reporters can be held criminally responsible if they fail to report suspected abuse or neglect. We take this responsibility very seriously and will make all warranted reports to the appropriate authorities. The Child Protective Services Act is designed to protect the welfare and best interest of all children. As mandated reporters, the staff of Family Gateway cannot be held liable for reports made to Child Protective Services which are determined to be unfounded, provided the report was made in “good faith.” Causes for reporting suspected child abuse or neglect include, but are not limited to: ·Unusual bruising, marks, or cuts on the child’s body; ·Severe verbal reprimands; ·Improper clothing relating to size, cleanliness, season; ·Transporting a child without appropriate child restraints (e.g. car seats, seat belts,etc.); ·Dropping off or picking up a child while under the influence of illegal drugs or alcohol ·Not providing appropriate meals including a drink for your child; ·Leaving a child unattended for any amount of time; ·Failure to attend to the special needs of a disabled child; ·Sending a sick child to school over medicated to hide symptoms, which wouldtypically require the child to be kept at home until symptoms subside. ·Children who exhibit behavior consistent with an abusive situation. I understand that Family Gateway staff is mandatory reporters of suspected child abuse. I realize that while on Family Gateway I am NOT to physically discipline my child under any circumstances. I realize and understand the causes for reporting suspected child abuse or neglect.
E-Signature of Guest 1 (please type first & last name):*
E-Signature of Guest 2 (please type first & last name):
Date:*
MM slash DD slash YYYY
Crisis Stabilization Plan
Applicant 1 Name:*
First Last
Applicant 2 Name:
First Last
Date of Plan:*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Next Review Date:*
MM slash DD slash YYYY
Goal 1:
Goal 2:
Goal 3:
Goal 4:
Action Steps for Goal 1 (what, purpose, who needs to complete, date to complete by):
Action Steps for Goal 2 (what, purpose, who needs to complete, date to complete by):
Action Steps for Goal 3 (what, purpose, who needs to complete, date to complete by):
Action Steps for Goal 4 (what, purpose, who needs to complete, date to complete by):
Acknowledgment*
The above barriers, goals and action steps were developed in partnership with A&D specialist. I understand that each barrier, goal and action step listed above will support my efforts in resolving my immediate housing crisis. I agree to work on these goals. I will update the A&D specialist as I complete the above goals and will communicate any challenges I experience and understand the A&D specialist can offer me support as needed. Failure to work toward achievement of these goals could result in termination from the program.
E-Signature of Guest 1 (please type first & last name):*
E-Signature of Guest 2 (please type first & last name):
Date:*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Hotel Signature Form

City of Dallas ESG Program: Confidentiality/Release of Information

Statement of Confidentiality

Emergency/Alternate Contact

Request for Shelter Agreement

Family Gateway Crisis Hotel Stay Program Statements of Understanding

Family Rights & Responsibilities

Acknowledgment of Welcome Packet

Acknowledgment of Orientation

Hotel Guest Policies & Responsibilities

Release of Liability

Personal Possessions

Mandated Reporting of Suspected Child Abuse & Neglect

Crisis Stabilization Plan