Member Application Packet Kiesler Wellness Center Application Step 1 of 5 20% Date MM slash DD slash YYYY Email Name First Last PhoneDate of Birth MM slash DD slash YYYY Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Name: First Last Emergency Contact Phone:Medication Management Provider, if applicable: Current Medications (particularly as needed medications):Allergies: Do you carry and Epi-Pen? Yes No Mental Health Diagnosis: Other Important Information to the safety of the individual, others, and property or important medical information, such as seizure disorder or diabetes: Name First Last Today's Date: MM slash DD slash YYYY Consent I have read and understand all the rules and regulations in the guidelines for Kiesler Wellness Center.GUIDELINES FOR KIESLER WELLNESS CENTER As the Kiesler Wellness Center Director it is my opinion that members can and should be responsible for their actions and behaviors. There could be instances where mental health is affecting a person’s behavior, but this will not be considered an excuse for Disrespectful Behavior. RESPECT! The key to the success of the Kiesler Wellness Center is respect for your fellow members and staff. What is respect? Remember the Golden Rule – Treat others as you would want to be treated. NEGATIVE BEHAVIORS: Rude, disrespectful, disruptive behavior will be considered abusive and destructive to other members’ mental health. These behaviors will result in disciplinary action from staff/management. CONFIDENTIALITY: Any information about a members’ health is considered confidential and private. Violations of this will result in suspension. VIOLENCE: Will result in the immediate termination of membership and expulsion from the building. STEALING: Stealing from members or staff will result suspension or termination of membership. VULGER LANGUAGE: There will be no obscene language at Kiesler Wellness Center or on the premises. LYING/MANIPULATIVE BEHAVIOR: Members/staff will not lie, manipulate or spread rumors about others in any way. BOUNDARIES: Listening when people say no, giving people personal space, not taking advantage of other, not interrupting, gossiping, rumors and negative talk of others will not be tolerated. VIOLATORS WILL RECEIVE THE FOLLOWING CONSEQUENCES Staff/management will determine the consequences for the behavior of the individual in consultation with involved members and responsible parties. The consequences may vary due to circumstances such as Mental Health Status, Frequency of behavior, and Degree of offense. Signature Name First Last Today's Date: MM slash DD slash YYYY Consent I have read and understand all the rules and regulations in the guidelines for Kiesler Wellness Center.Kiesler Wellness Center Policies Fraternization Policy No employee or staff shall enter into, nor take advantage of any personal, social, or business relationship with a current member/staff. Personal gain includes, but is not limited to engaging in dating and/or sexual relationships with a current member/staff. Staff may assist members in accessing banking and other financial resources, and may help a member fill out paperwork, but may not do the actual transactions themselves. Exception is given if a third party is witness and approves of a transaction, and there is a fair and equitable financial transaction. Sexual misconduct from staff or members is strictly forbidden. This includes unwanted sexual language, physical touching or aggression in any way. For outside Kiesler Wellness interaction, personal discretion is advised. Members should initiate approaching staff, and will be responsible for communication to staff and other members if they wish to remain anonymous outside of Kiesler Wellness Center. Staff and other members are required to respect the request to not be acknowledged outside of the Kiesler Wellness Center. Friendships between staff and members prior to membership may remain the same providing there is no conflict of interest, no personal gain, and no discrimination caused to them or others. Sexual relationships with current members by staff are absolutely forbidden. An employee should never take advantage of a Kiesler member, nor should a Kiesler member be allowed to compromise an employee through a social relationship. Consensual nurturing of a non-sexual nature is encouraged. In regards to after-hours outreach, another staff or member will be informed in regards to member-to member interaction. Gift Giving: Gift giving between staff and members shall not exceed nominal value (example is $5.00). The exchange of token gifts is permitted. Signature Name First Last Today's Date MM slash DD slash YYYY Consent I have read and consent to the Kiesler Wellness Center Drug and Alcohol PolicyKiesler Wellness Center Drug & Alcohol Policy and Procedure Kiesler Wellness Center will not tolerate any drug or alcohol use on the property. This means while on their property one cannot be under the influence of any drugs or alcohol, have drugs or alcohol on their person, promote the use of drugs or alcohol, and /or cannot be seeking or attempting to sell drugs or alcohol. Kiesler Wellness Center holds the right to call law enforcement and the following consequences listed below, if it is suspected one is under the influence or has drugs or alcohol on their person. If you are promoting the use, seeking or attempting to sell drug and/or alcohol you will also be suspended until: 1st Offense: A meeting with _________ , at Northland Recovery Center has been completed Recommendations have been started, and a letter from treatment team stating that you have begun recommendations. Members will then get together and vote to continue your membership at Kiesler Wellness Center. 2nd Offense: A meeting with __________, at Northland Recovery Center has been completed Recommendations have been followed and completed 6 month suspension – upon return a note stating treatment has been completed Members will then get together and vote to continue your membership at Kiesler Wellness Center Friendly Reminder: Kiesler Wellness Center staff reserves the right to a drug test members if they are suspected of using drugs and/or alcohol while on the premises. Kiesler Wellness Center may ask members to submit to a drug test for extended out of town events. In the event that a member refuses to submit a drug test or fails a drug test, that member will not be allowed to participate in the out of town event. (NOTE: synthetic chemicals are included) Consent I agree to the following:I will not come to Kiesler Wellness Center under the influence of drugs or alcohol, have drugs/alcohol on my person, promote the use of drugs and alcohol, and or come to Kiesler Wellness Center to seek or attempt to sell drugs or alcohol. I have read and understand the consequences if I do not comply.Signature Name First Last Today's Date: MM slash DD slash YYYY Consent By checking this box you grant permission to the use of your photo for the below reasons:KIESLER WELLNESS CENTER Photography Waiver and Release Form Kiesler Wellness Center periodically use photographs, videos, art work, profiles, and stories for products which are promotional, advertising, commercial, educational, or community activities. As such, Kiesler Wellness Center collects on an ongoing basis individual and group photos and testimonials related to our volunteers, supporters and activities. We ask for permission to use your photo, profiles, and /or story in promotional materials to promote and benefit our projects and programs. I, hereby grant Kiesler Wellness Center the legal representatives the irrevocable right and unrestricted permission to use and publish photographs or video images, art work, and quotations of me, or in which I may be included, for any purpose authorized by Kiesler Wellness Center, including but not limited to: website use, newspaper editorial publications, catalog, and advertising use community art displays. Kiesler Wellness Center will to the best of its ability notify the each individual about the media event. Furthermore, I understand that I will not be given the opportunity to inspect or approve the finished products or the advertising copy or the printed matter which may be used in representatives, I am fully and without limitation releasing it from liability which may arise from the use of said images. I agree for Kiesler Wellness Center to utilize my name for the above indicated reasons: Yes No Signature