VISION

To Create and Sustain Healthy and Safe Neighborhoods through Action Focused Youth Leadership

Coalition Purpose:

United Way of Broward County Commission on Behavioral Health & Drug Prevention (UWBCCBHDP) recognizes the power of youth as key leaders who can make long, lasting significant change in the their communities. The Broward Youth Coalition (BYC) is an initiative of UWBCCBHDP. The BYC is a group of middle and high school drug free youth leaders representing all areas of the local community. This cadre of youth leaders come together on a regular basis to create, develop and put into action positive, social change activities as it relates to substance use, mental health awareness & other interrelated issues.

We empower our youth to be change agents, leaders, and promote healthy drug free communities. Some of the Broward Youth Coalition's goals include:

Youth Leadership Development
Education to the Community about Substance Use and Abuse
Playing an active role in promoting positive social norms

Student Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

School Name *

Are you a part of your school's BYC club? *

Yes

No

Current Grade *

Select your current school year *

Age *

T-Shirt Size *

Race/Ethnicity *

Gender Identity *

Legal Guardian / Emergency Contact

First Name *

Last Name *

Relationship to student *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

I, the LEGAL GUARDIAN, give permission for my child to be a member of Broward Youth Coalition *

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Behavioral Support Management Philosophy & Procedures

United Way of Broward County behavior support and management policies and practices promote positive behavior and protect the safety of participants, volunteers, stakeholders and staff members. United Way of Broward County does not employ restrictive behavior management interventions, defined as isolation, manual restraint, mechanical restraint and locked seclusion.

LEGAL GUARDIAN'S SIGNATURE *

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Acknowledgment of UWBC Behavioral Support Management Philosophy and Procedures

STUDENT SIGNATURE *

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Photograph/Media Release Form

I do hereby give United Way of Broward County their assigns, licensees, and legal representatives the irrevocable right to use my child’s name / or any fictional name, photograph image and/or statement(s) in all forms and media and in all manners, including composite or distorted representations, for advertising, trade or any other lawful purposes, including on printed advertising and promotional material and on websites and other electronic media and I waive any right to inspect or approve the finished version(s), including written copy that may be created in connection therewith. This consent is expressly intended to release United Way of Broward County from liability. I am of legal age and have read this release and am fully familiar with its contents.

LEGAL GUARDIAN'S SIGNATURE *

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Acknowledgment of Photo/Media Release

STUDENT SIGNATURE *

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Code of Conduct

I understand that BYC is a substance abuse prevention program, in which I have an option to participate. I accept my responsibility to engage in program activities and to excuse myself from this program if it does not meet my personal learning objectives. I recognize the organization has the responsibility and authority to remove youth who are disruptive to the BYC program or for any other reason BYC program deems appropriate.
I accept my responsibility to represent United Way of Broward County Commission on Behavioral Health & Drug Prevention (UWBCCBHDP) - BYC program by holding myself to the standards of BYC’s mission. I will refrain from behavior that negatively represents myself, my family, my community, and BYC or UWBCCBHDP.
I accept my personal responsibility to be informed and follow the policies, rules, and deadlines established by UWBCCBHDP-BYC. I will not knowingly furnish false information, deceive, or otherwise engage in dishonest, unethical or illegal behaviors. I will not encourage others to disregard or intentionally violate conditions of UWBCCBHDP-BYC participation.
I will act in a respectful and responsible manner during all BYC activities. I will comply with the directions of UWBCCBHDP staff acting in the performance of their duties. I will not obstruct or disrupt any BYC program or encourage others to engage in such conduct. I understand that the BYC staff makes the final decision on activities.
I will promote a spirit of inclusion and welcome participation of individuals from all backgrounds. I will practice fair-mindedness by being open to ideas and opinions of others. I will not participate in behaviors that discriminate against other people.
I will communicate (oral, written and electronic) in an open, honest, respectful manner in all situations involving the BYC program. I will refrain from communication that is negative, offensive, destructive or hurtful to others. I will refrain from sharing private matters in a public group setting. I will not engage in or tolerate slander, put-downs, insults, taunting, name calling, yelling, profane language, sexual innuendos and other comments or hostile behaviors likely to offend, hurt or set a bad example. If I witness is type of behavior, I will contact a volunteer or staff member. If the situation is escalating to where I feel unsafe, I will contact the authorities.
I will make healthy choices. I will not possess or use tobacco, alcohol or illegal drugs/substances.
I will dress in a manner that is appropriate, tasteful and respectful to me and others. I will avoid clothing and accessories that depict violence, sex, drugs, alcohol, tobacco, death, gangs or other offensive or obscene pictures or language.
I will demonstrate behaviors appropriate as a positive role model. If I have a guest or guests in attendance at a BYC activity, I will encourage them to abide by the UWBCCBHDP-BYC code of conduct. I recognize that if the guest’s behavior interferes with the learning, my guest may be asked to leave the BYC program.
As a member of BYC I can expect to be treated fairly by all UWBCCBHDP staff. I have the right to file a grievance without fear of coercion, interference, discrimination, or reprisal, and will be free from harassment or retribution. I acknowledge receipt of grievance policy.

YOUTH ACKNOWLEDGEMENT OF THE UWBCCBHDP-BYC CODE OF CONDUCT
I have read, accept, and will abide by the code of conduct set forth by United Way of Broward County Commission on Substance- Broward Youth Coalition program. I understand that the expectations apply throughout my membership. I also understand that infractions of the UWBCCBHDP-BYC Code of Conduct will result in consequences and that these consequences may result in removal from BYC activities and or membership. I will accept the consequences determined UWBCCBHDP-BYC program staff.

Student Signature *

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Acknowledgement of Code of Conduct
Legal Guardian Signature *

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Grievance Process for Participants

Customer satisfaction is very important to the United Way of Broward County Commission on Behavioral Health & Drug Prevention. To that end, participants are made aware of their rights and responsibilities when enrolling in any prevention services offered by the UWBCCBHDP, and staff members are available to answer any questions or concerns, to respond to problems or complaints, and to assist in any way to assure that their rights are protected and respected. If a participant, including family members and/or a guardian of a participant, is dissatisfied with the service received or with information provided or feels their rights have been violated, s/he is encouraged to first ask to speak to a Supervisor, Manager or Director to resolve the issue as an informal inquiry. The BCCBHDP’s goal is to resolve complaints quickly and amicably to the best of our ability. Having done that, if a participant is not satisfied with the actions taken, s/he may file a grievance. The participant must file or report their grievance within 30 calendar days after becoming aware of the basis for the grievance or of the UWBCCBHDP response to the initial, informal inquiry, whichever comes later.
Participants will have access to grievance forms at all times. Participants have the right to file a grievance without fear of coercion, interference, discrimination, or reprisal, and will be free from harassment or retribution as protected by State and Federal laws (Whistle Blower protection).
Once a complaint is received by UWBCCBHDP, the staff member shall ask the participant if he/she wishes to resolve the issue informally or to file a grievance in writing. If the participant wishes to file a written grievance, the staff member shall provide the participant with a Grievance Report Form and, if necessary, assist the participant in completing the form. If the participant wishes to resolve the issue informally, the staff member shall be responsible for documenting the complaint on the Grievance Report Form and notifying the Senior Director of UWBCCBHDP of the complaint.
The Senior Director, or designee, will address and/or attempt to resolve the grievance or informal complaint with the participant within 48 hours and will notify the participant of the proposed resolution in writing within 24 hours of the initial contact. If the participant is not satisfied with the proposed solution, the Vice-President of Programs will follow-up with the participant within five (5) business days. If after working with the Vice-President of Programs, the participant is still not satisfied with the proposed resolution, the grievance will be reviewed by the President/CEO, or designee, within ten (10) business days of his/her receipt of the grievance. The decision of the President/CEO is final. If the participant does not agree with the final United Way resolution, the participant may request that the funding agency’s grievance procedure be initiated at that point.*
All actions taken toward the resolution of the grievance shall be documented on the Grievance Report Form. The UWBCCBHDP will log and track all grievances in order to analyze trends in order to identify opportunities for process improvement.
*If the service in question is funded by the Broward Behavioral Health Coalition (BBHC), the participant may appeal to the BBHC for a final determination directly by calling 1-877-698-7794. A participant may, at any time, contact the Department of Children and Families Participant Relations Specialist/Human Rights Advocacy Committee (954-713-3027) or Abuse Hotline (1-800-96ABUSE) to express a complaint.
Student Signature: *

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Acknowledgement of Grievance Process for Participants
Legal Guardian Signature *

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Rights & Responsibilities

United Way of Broward County Commission on Behavioral Health & Drug Prevention (UWBCCBHDP) supports and protects the fundamental human, civil, constitutional and statutory rights of each participant.

Participants are treated with full respect and dignity regardless of race, religion, sex, ethnicity, physical disability, age, sexual orientation or mental illness.

Participants will be made aware of their rights when signing up for any prevention services offered by UWBCCBHDP. UWBCCBHDP will make staff members available to answer any questions or concerns, respond to problems or complaints, and to assist in any way to assure that their rights are protected and respected.

Participants, including family members and/or guardians of the participant, may file grievances for any reason with cause and have access to grievance forms at all times. All parties who express their right to file a grievance will be free from harassment or retribution, as protected by State and Federal Laws.

If the service in question is funded by the Broward Behavioral Health Coalition (BBHC), the participant may appeal to the BBHC for a final determination directly by calling 1-877-698-7794.

A participant may, at any time, contact the Department of Children and Families Participant Relations Specialist/Human Rights Advocacy Committee (954-713-3027) or Abuse Hotline (1-800-96ABUSE) to express a complaint.

Student Signature *

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Acknowledgement of Rights & Responsibilities
Legal Guardian Signature *

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End of form.