CaringKind Participant Agreement

We are glad for you to be a part of our programs at CaringKind!

We are committed to providing personalized and quality programs at CaringKind. Getting to know a bit of information about everyone we serve helps us improve and sustain our programs. Learning more about you also helps us better meet your needs now and into the future.

Please enter the requested information below and read our commitment to safeguard your privacy. You can type your name or sign this agreement at the end to confirm your participation in our programs. If you would like a hardcopy of this information, just ask and we will send you one. You will get an email copy when you submit the form.

Thanks for your interest in being a part of our programs, and if you have any questions, feel free to call us at: 646-744-2900
Tell us a bit about yourself.

At CaringKind, we are committed to safeguarding your privacy. We will not share your information with anyone without your permission.
How would you best describe yourself?*

I support/care for someone with a memory or cognitive disorder (Mild Cognitive Impairment, Alzheimers' or another Dementia)I am a person with a memory or cognitive disorder (Mild Cognitive Impairment, Alzheimers' or another Dementia)I work as a direct care providerI am a aging/dementia services professional
Participant Information*

I am completing this form for myselfI am completing this form for someone else
Work/Occupation*

Any IDD providersInformation and referral providers, option counselorsCase managers, care coordinators, discharge plannersOther dementia-related program providersDirect care workersMedical care providersAllied health providersVolunteersFirst respondersLegal professionalsFinancial professionalsCommunity businessesClergy, other members of faith communityStudents preparing for dementia-related workOther
Tell us a bit about the person participating in the CaringKind program.

At CaringKind, we are committed to safeguarding everyone's privacy. We will not share contact information with anyone without permission. Please complete the information below for the person participating in the CaringKind program.
Name of Program Participant*

First NameLast Name
Participant's Best Email*
example@example.com
Participant's Best Phone Number*
Please enter a valid phone number.
How did you hear about our program?*
PWD

YesNo
Address*
City*
State *
Zip*
Additional Participant Information

As a part of our reports for certain funders, we are required to provide additional information on our program participants. Any reported information will NOT be associated with your name or any other identifying information. If you have questions about how your data is shared, please contact our Chief Evaluation, Grants and Research Officer, Dr. Ed Cisek at ecisek@cknyc.org or by calling 646-744-2953.
Participant's Year of Birth*
Please enter 4 digits.
Participant's gender?*

Woman/FemaleMan/MalePrefer to not answer
Participant's military status?*

Served in the militaryHas not served in the military
Participant's geographic location*

Urban Area (greater than 50,000 people)Rural Area (less than 50,000 people)
Participant's ethnicity?*

Hispanic or LatinoNot Hispanic or LatinoPrefer to not answer
Participant's race?*

American Indian or Alaskan NativeAsian or Asian AmericanBlack or African AmericanMiddle Eastern North African (MENA)Native Hawaiian or other Pacific IslanderWhiteOtherPrefer to not answer
Additional information

At CaringKind, we are committed to safeguarding your privacy. In 2022 the questions in the reporting tool used for federal grants (OMB 0985-0022) was updated by the Office of Management and Budget (OMB). The new questions are included for your review below. Any information provided below will NOT be associated with your name or any other identifying information in any reports we are required to provide to the OMB. Please note - All questions include the option, "Prefer not to answer".
Additional information

At CaringKind, we are committed to safeguarding your privacy. In 2022 the questions in the reporting tool used for federal grants (OMB 0985-0022) was updated by the Office of Management and Budget (OMB). The new questions are included for your review below. Any information provided below will NOT be associated with your name or any other identifying information in any reports we are required to provide to the OMB. Please note - All questions include the option, "Prefer not to answer".
How would you describe your sexual identity

Prefer to not answerHeterosexual / StraightLesbian or GayBisexualUse a different term
Do you identify as transgender?

Prefer to not answerYesNo
Is there someone else who should be listed as an Additional Contact for email correspondence or phone calls?

YesNo
Name of Additional Contact for Correspondence

First NameLast Name
Additional Contact's Best Phone Number
Please enter a valid phone number.
Additional Contact's Best Email
example@example.com
Relationship of Additional Contact to you (for example spouse, daughter, friend, partner)
Questions for Support/Care Partners
Name of the Support/Care Partner:

First NameLast Name
What is your relationship to the person you support or care for?

Spouse/PartnerChildSiblingFriendOther Family MemberOther
Are you their primary caregiver?*

YesNoPrefer to not answer
What is the living arrangement of the person you support or care for?

Lives alone, has an identified caregiverLives alone, has no identified caregiverLives with caregiverLives with someone who is not a caregiver
Our Mutual Agreements

I am voluntarily participating in a non-medical program/service offered by CaringKind. I grant permission to CaringKind to exchange my and/or my care/support partner’s personal and health related information with other medical and/or service professionals to maximize my/our support, education, health, well-being, and coordination of care and services. I understand that the information I provide will not be disclosed or shared with any other entity without my additional authorization. I understand that this permission can be revoked at any time by contacting CaringKind. I understand CaringKind is committed to safeguarding my privacy and that the costs associated with CaringKind's programs are covered through grants, donations, fundraising and philanthropy. To help CaringKind and its funders learn more about program participants, I will share my demographic and contact information. I will also complete questionnaires to help CaringKind measure and enhance the quality of their services. My responses will only be used for program and reporting purposes and will not be disclosed for any other reason without my additional authorization. I also understand that programs may be video/audio recorded for internal training and quality assurance purposes. CaringKind will not publicly share any video recordings without my additional authorization. My responses may be shared anonymously for testimonials, but I will not be personally identified outside of CaringKind without my permission. I recognize the value of CaringKind’s services and commit to fully participating in the service being provided to me. I will attend all service sessions as planned unless an unexpected conflict arises. If I need to cancel an appointment, I will provide a minimum of 24 hours’ notice and will contact my service provider directly or through the CaringKind Helpline at: 646-744-2900. I am voluntarily participating in CaringKind's services and I or my successors will not hold CaringKind, its Board of Directors, volunteers, and/or staff liable for any injury or damages due to my own negligence or compromised physical/cognitive abilities. I will also arrange for my own assistance with care and transportation needs for in before/during/after in person programs as I understand CaringKind staff/volunteers will not be able to assist with my personal care needs (including using the restroom, public transportation, etc.) unless a formal arrangement has been made in advance.
Please check the box below to confirm your agreement with the above statements and authorize your electronic signature below:

Agreed
Your Signature
Today's Date*

MonthDayYear
Date
Form ID
RecordType ID
Should be Empty:

Tell us a bit about yourself.

Tell us a bit about the person participating in the CaringKind program.

Additional Participant Information

Additional information

Additional information

Questions for Support/Care Partners

Our Mutual Agreements