DPI (Davidson Program for Independence) Student Application

STUDENT/PARENT/GUARDIAN
MEDIATION AND ARBITRATION AGREEMENT This is an Agreement to mediate and arbitrate all unresolved disputes arising from the educational, recreational, special education school, and residential services between the undersigned student and/or their legal guardian and the Wayfinder Family Services.
In the event of any unresolved dispute, claim or controversy by the student and/or their legal guardian against Wayfinder Family Services, its directors, officers, employees or agents, the student and/or their legal guardian agrees to submit such unresolved dispute, claim or controversy, including but not limited to all claims for breach of contract and civil torts, to non-binding mediation before a neutral independent third-party mediator and, if that process does not result in full resolution of the dispute, to final and binding arbitration, including, but not limited to, claims for breach of contract and civil torts.
The arbitration shall be conducted by a single-arbitrator selected either by mutual agreement of the student and/or their legal guardian and the Wayfinder Family Services or, if they cannot agree, from an odd-numbered list of experienced arbitrators provided by the American Arbitration Association. Each party shall strike one arbitrator from the list alternately until one arbitrator remains. The arbitrator shall have all powers conferred by law and a judgment may be entered on the award by a court of law having jurisdiction. The award and judgment shall be in writing and binding and final on both parties.
Each party shall have the right to conduct reasonable discovery, as determined by the arbitrator and as provided in California Code of Civil Procedure Section 1283.5(a).
The parties agree to submit any unresolved dispute or unresolved controversy arising out of or relating to the terms of the Agreement to mediation, and if that process does not result in full resolution of the dispute to final and binding arbitration by a single neutral arbitrator.
Wayfinder Family Services agrees to pay for 75% of the costs of the mediation and arbitration proceedings and the fees of the arbitrator. The remaining 25% of the costs and fees of the mediation and arbitration will be paid by the student and/or their legal guardian. Recognizing that parties involved in any such dispute may have limited resources, the parties agree to endeavor in good faith to identify a mediator and an arbitrator whose fees and costs are reasonable and affordable in light of that fact.
This agreement shall continue during the period of service delivery and thereafter regarding any related disputes. This agreement may only be modified for the Wayfinder Family Services by a written agreement signed by the President of the Wayfinder Family Services.
The student and/or their legal guardian understand that by signing this Agreement, he/she gives up his/her right to a civil trial and his/her right to a trial by jury.
If any of the provisions of this Agreement are found null, void, or inoperative, for any reason, the remaining provisions will remain in full force and effect. I have read, understand, and received a copy of this document.

PARTICIPANT REPORT OF SELF-CARE
The Davidson Program for Independence is a residential program that provides instruction in the non-visual techniques for completing independent living tasks. Participation in the program is dependent on each applicant’s ability to independently perform basic activities of daily living. The program may provide instruction in how to complete these tasks more effectively and efficiently, however applicants must be able to manage their own basic care needs upon entering the program and throughout the duration of training.


DPI Staff do not provide client assistance with any of the below listed activities of daily living which the participant must complete independently:
-Able to communicate needs
-Able to administer and store own medications
-Able to dress self
-Able to bathe self
-Able to feed self
-Able to care for his/her own continence and toilet needs
-Able to independently transfer to and from bed
-Able to manage own cash resources


I acknowledge that I am responsible for my own basic care including maintaining my medications, cash resources, hygiene, feeding, dressing, and bathing without the assistance of DPI staff throughout the duration of the training program.

ALTERNATIVE ELECTRONIC COMMUNICATION POLICY AND REQUEST FORM
PURPOSE
The purpose of this policy is to establish guidelines for alternate electronic communications. By signing this policy and request form, the therapist/caregiver and client (or parent, guardian, representative) are agreeing to the following:

TERMS AND CONDITIONS
1 . Client has a legal right to only communicate with Wayfinder Family Services staff using methods that guarantee privacy and keep client Protected Health Information (PHI) confidential and secure.
2. Communicating by unencrypted email and text messaging is not secure. It is possible for people to intercept or read the messages without client’s knowledge or permission. Communicating with Wayfinder Family Services staff in this manner is a client option, and if client elects to do so, the client will give up the right to secure and private communications as defined by Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other state and federal laws.
3. Client has the right to limit what kind of information Wayfinder Family Services staff can communicate using alternate electronic communication methods (refer to the Request Form section).
4. Only the minimum necessary PHI or other confidential information may be communicated via unsecured email or text messaging. I understand and agree to the following:
-Unsecured email and text messaging does not replace, and is not a suitable replacement for, communication in person or by voice telephone.
-Unsecured email and text messaging does not replace, and is not a suitable replacement for, communication in person or by voice telephone.
-The use of unsecured email and text messaging will be kept to a minimum and will primarily be used to communicate regarding appointments and similar information.
-No information related to HIV/AIDS may be communicated via unsecured email or text message.
-No unsecured email or text message to or from a client or personal representative will be forwarded to any person or agency.

5.Wayfinder Family Services has the right to withdraw this form of communication if the terms or conditions are violated.
6.Client’s Responsibilities:
-Staff may not be able to read email or text messages promptly, so the client should call Wayfinder Family Services staff if there is a time sensitive need to communicate.
-In case of emergency, client should call 911 instead of sending an email or text message.
-If staff tells client that communication needs to be in person or by talking on the phone, client must follow through.
-Client may cancel this request/authorization at any time by notifying their assigned Wayfinder Family Services staff member. The cancellation request is only effective from the date staff receives client’s cancellation, and not retroactively.
-Any text message to/or from Wayfinder Family Services staff members may not be photographed nor placed on any form of social media.
7.Wayfinder Family Services Staff Responsibilities:
-It is staff’s responsibility to delete text messages on his/her smartphone or other device so that other people cannot read them.
-Staff will only communicate with clients via approved devices and using the company approved email system and their individual email account.

I request that the following communications from Wayfinder Family Services be delivered to me by the provided electronic means. I understand that this form of communication may not be secure, creating a risk of improper disclosure to unauthorized individuals. I am willing to accept that risk and will not hold Wayfinder Family Services responsible should such incident occur.

Acknowledgement and Agreements:
I understand and agree that the requested communication method is not secure, making my PHI at risk for receipt by unauthorized individuals. I accept the risk and will not retaliate against Wayfinder Family Services in any way should this occur. I have read, understand, and received a copy of this document.

BEHAVIOR MANAGEMENT POLICY
It is the policy for the Davidson Program for Independence (DPI) to ensure that every client is treated with dignity and respect. Whenever feasible, staff will diffuse a situation involving disruptive behavior verbally and/or physically in a non-restraining technique. However, if, in the judgement of staff, the above methods are inappropriate, further measures may need to be taken.
DPI staff are forbidden from physically restraining a DPI client unless that individual is being physically harmful to him/herself or others. In the event this is the case, it is the responsibility of the staff person present to determine whether it is possible to intervene alone or to request assistance from other Wayfinder Family Services staff or to call 911, if warranted.
I understand and agree with this policy and authorize its execution by the DPI. This authorization is valid for a period of one (1) year.

AUTHORIZATION FOR TREATMENT/TRIPS/PHYSICAL ACTIVITIES CONSENT, RELEASE & COVENANT The undersigned or parent (s) or guardian represents to the Wayfinder Family Services that the person named below is in his and / or her legal custody and control, and that the undersigned desires said person to participate in the programs of the Wayfinder Family Services, and that for purposes of said participation, the undersigned agrees, authorizes, and states as follows:
1. In case of medical or dental need or emergency, I (we) understand every effort will be made to contact spouse, next of kin, parents, or guardian of person. In the event they cannot be reached, I (we), the undersigned, or parents of, do hereby authorize the Wayfinder Family Services and its officers or staff employees, as agent (s) for the undersigned to obtain and consent to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis, or treatment and hospital care, which is deemed advisable by, and is to be rendered to said person under the general or special supervision of any physician and surgeon licensed under the provisions of the Medical Practice Act or the medical staff of a licensed hospital, or by a dentist licensed under the provisions of the Dental Practice Act, whether such diagnosis or treatment is rendered at office of said physician or dentist or at said hospital.
I (we) also understand and agree that any and all such medical, dental, hospital or similar expenses incurred in the treatment will be borne by myself (ourselves), except to the extent that those connected with activities at Camp Bloomfield are covered by Camper’s Health and Accident Insurance (or similar insurance) if such insurance if such insurance is in effect for said person. (We understand that that no representation that such coverage exists is intended by this form.)
It is understood that this authorization is given in advance of any specific medical or dental diagnosis, treatment, or care being required, but is given to provide authority and power on the part of the Wayfinder Family Services (as aforesaid) as my (our) agent (s), to give specific consent to any and all such diagnosis, treatment, or care which a licensed physician or dentist in the exercise of his best judgment may deem advisable.
This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. This authorization shall remain effective for 12 months, unless sooner revoked in writing and delivered to agent(s).
2. Permission is granted for trips or walks away from the Wayfinder Family Services premises when the staff deems such trips or walks to be of benefit. Furthermore, permission is granted for him / her to take part in playground and other physical activities.
3. The undersigned further releases the Wayfinder Family Services, its officers, agents, and employees, from any and all legal responsibility for accidents or sickness occurring during or related to the period of time said person is a participant in programs of the Wayfinder Family Services including, but not limited to, its summer camp program at Camp Bloomfield. I (we) further agree and covenant (for valuable consideration receipt of which is acknowledged) that neither said person nor I (we) will institute any suit or action of damage, loss or injury of any kind whether to person or property, whether to me (us) individually or as parent (s) or guardian relating to the programs or activities or the Wayfinder Family Services (including but not limited to Camp Bloomfield) in which the person participates.

DECLARATION OF SELF RESPONSIBILITY FOR PARTICIPANTS IN DPI
The undersigned or parent (s) or guardian represents to the Wayfinder Family Services that the person named below is in his and / or her legal custody and control, and that the undersigned desires said person to participate in the programs of the Wayfinder Family Services, and that for purposes of said participation, the undersigned agrees, authorizes, and states as follows:
1. In case of medical or dental need or emergency, I (we) understand every effort will be made to contact spouse, next of kin, parents, or guardian of person. In the event they cannot be reached, I (we), the undersigned, or parents of, do hereby authorize the Wayfinder Family Services and its officers or staff employees, as agent (s) for the undersigned to obtain and consent to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis, or treatment and hospital care, which is deemed advisable by, and is to be rendered to said person under the general or special supervision of any physician and surgeon licensed under the provisions of the Medical Practice Act or the medical staff of a licensed hospital, or by a dentist licensed under the provisions of the Dental Practice Act, whether such diagnosis or treatment is rendered at office of said physician or dentist or at said hospital.
I (we) also understand and agree that any and all such medical, dental, hospital or similar expenses incurred in the treatment will be borne by myself (ourselves), except to the extent that those connected with activities at Camp Bloomfield are covered by Camper’s Health and Accident Insurance (or similar insurance) if such insurance if such insurance is in effect for said person. (We understand that that no representation that such coverage exists is intended by this form.)
It is understood that this authorization is given in advance of any specific medical or dental diagnosis, treatment, or care being required, but is given to provide authority and power on the part of the Wayfinder Family Services (as aforesaid) as my (our) agent (s), to give specific consent to any and all such diagnosis, treatment, or care which a licensed physician or dentist in the exercise of his best judgment may deem advisable.
This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. This authorization shall remain effective for 12 months, unless sooner revoked in writing and delivered to agent(s).
2. Permission is granted for trips or walks away from the Wayfinder Family Services premises when the staff deems such trips or walks to be of benefit. Furthermore, permission is granted for him / her to take part in playground and other physical activities.
3. The undersigned further releases the Wayfinder Family Services, its officers, agents, and employees, from any and all legal responsibility for accidents or sickness occurring during or related to the period of time said person is a participant in programs of the Wayfinder Family Services including, but not limited to, its summer camp program at Camp Bloomfield. I (we) further agree and covenant (for valuable consideration receipt of which is acknowledged) that neither said person nor I (we) will institute any suit or action of damage, loss or injury of any kind whether to person or property, whether to me (us) individually or as parent (s) or guardian relating to the programs or activities or the Wayfinder Family Services (including but not limited to Camp Bloomfield) in which the person participates.

CONFIDENTIALITY AND PRIVACY NOTICE OF CONFIDENTIALITY AND PRIVACY PRACTICES
The privacy of your personal and health information (PHI) is important to us. This notice describes how your PHI may be used and disclosed and how you can have access to this information.
Protecting Your Personal Health Information
Wayfinder Family Services understands the importance of keeping your PHI private. In accordance with the State and Federal Law, this notice describes Wayfinder Family Services’ privacy practices. We may modify or change our privacy practices from to time to time, particularly as new laws and regulations become effective. When that occurs, we will provide you with a new notice advising you of the changes. For more information about our confidentiality and privacy practices, or for additional copies of this notice, please contact us.
-Wayfinder Family Services may use and disclose your PHI without your authorization only in the following ways:
-Treatment- Your PHI to a provider who requests this information to treat you.
-Payment-To pay claims for covered services provided to you.
-Health Care Operations- To conduct quality improvement activities, to engage in care coordination and case management and other similar activities.
-Health & Wellness- To contact you with information about health-related services, appointment reminders or treatment alternatives.
-Family and Friends- To a family member, friend or other person if you are unavailable to agree, such as in a medical emergency or disaster relief, only to the extent necessary to help with your health care or with payment of your care.
-Public Health & Safety- To avert a serious and imminent threat to your health or safety or the health or safety of others.

CONSENT FOR CONFIDENTIAL FILE MAINTENANCE AND ACCESSIBILITY
The privacy of your personal and health information (PHI) is important to us. This notice describes how your PHI may be used and disclosed and how you can have access to this information.
I understand that the Davidson Program for Independence maintains a confidential record for each client that contains information about the client when he/she receives services. I give consent that this file be accessible when necessary to DPI staff, authorized interns, medical service staff, the Director of Operations, and the Executive Director. I also understand that I have access to my record. This consent is valid for the period of one (1) year.

AIDS INFORMATION
AIDS is a much talked about subject. There is a great deal of misinformation regarding this disease. AIDS stands for acquired immunodeficiency syndrome and is caused by the Human Immunodeficiency Virus (HIV). HIV is widespread in the general population although only a small percentage of people are infected. Due to personal rights and testing inadequacies, there is no reliable way to know who may be infected or where an infected person may be. Since an infected person might be encountered in any location, we think the students and staff of the DPI should be informed about this incurable, always fatal disease.
AIDS has killed people mostly from these groups:
1. Men and women who share needles in taking drugs.
2. People who receive blood products contaminated with HIV.
3. Gay and bisexual men.
4. People who have sex with any of these people.
5. Children born to parents in these groups. However, it should be
remembered that anyone can get AIDS.

AIDS is an infectious disease. Although it is contagious, it is also very hard to contract. You cannot get AIDS / HIV from casual, social contact such as shaking hands, hugging, mouth-to-mouth kissing, coughing, sneezing, telephones, bathtubs, drinking fountains, insect bites, sharing drinking glasses, eating utensils, dishes, bathroom facilities, or being near a person with AIDS / HIV.
There are two main ways you can get AIDS. You can become infected by having sex – oral, anal or vaginal – with someone who is infected with HIV/AIDS, and you can be infected by sharing drug needles or syringes with an infected person. There is virtually no risk of contracting AIDS / HIV if you do not engage in sexual intercourse, do not share hypodermic needles or syringes and no not clean up bodily fluids or open wounds of someone infected with HIV without latex gloves on. If you do have sex, you must always use condoms and a spermicide containing Nonxynol-9 in order to protect yourself from HIV.
HIV is most concentrated in blood, lymphatic fluid, semen, vaginal fluid and human breast milk. HIV can live in the human body for years with the infected person showing no apparent symptoms. Therefore, infected persons often do not know that they are infected. For these reasons, you must assume that any person you meet could have AIDS / HIV. There is presently no cure for AIDS. There is no vaccine to prevent infected people from getting the infection, so the most effective way to prevent AIDS is avoiding exposure to HIV through controlling your behavior.
The above information was supplied by the San Francisco AIDS Foundation. If you need further information, we can direct you to the proper resources.
I have (had) read (to me) the AIDS information contained in this document. I understand that if I have any questions, I may ask the Medical Coordinator for further explanation or information.

CODE OF CONDUCT
Students are expected to observe certain standards of performance and conduct to ensure that our mission and our work is carried out in a safe and orderly way, and to ensure that we maintain high ethical standards throughout the organization.
Standards of Conduct
The WFS campus is a public place. Students are expected to conduct themselves as they would in any public area. Conduct which is not appropriate in public or which disrupts the safe and orderly operation of our business is considered inappropriate.
Conduct which is unsafe, unethical or illegal will not be permitted. Types of conduct which constitute grounds for immediate dismissal include, among other things, physical violence; illegal acts such as theft, use or possession of illegal drugs or weapons; sexual activity, and other areas as specified in the Students Handbook.
The following are examples of the kinds of misconduct that will lead to disciplinary action, up to and including dismissal.
-Excessive absences or tardiness
-Harassment in any form
-Falsification of records or other documents
-Abuse or neglect
-Possession or use of illegal drugs or controlled substances
-Alcoholic beverages on campus
-Being intoxicated and out of control on campus
-The use of offensive language in public places on WFS's campus.
-Theft, destruction or abuse of WFS’s property or the property of others
-Possession of weapons, firearms or other potentially dangerous weapons or materials on WFS’s property
-Involvement in, or the encouragement of illegal activities
-Acts of physical violence, or acts involving threats, intimidation or coercion
-Repeated lack of cooperation or courtesy in working with others, or failure to perform reasonable duties assigned in the classrooms and dorm
-Unauthorized access to computer files or inappropriate use of computer networks or utilities
-Disclosing or misusing private, proprietary or confidential information about WFS/Employment Services
-Unethical business practices or conflicts of interest
-Undermining or subverting business decisions, unless they are reasonably believed to be illegal or unethical
-Failure to adhere to other policies stipulated in our Student Handbook, student agreements or other WFS policies and procedures
It is not the purpose of this listing to indicate all grounds for disciplinary action. We ask that everyone conduct themselves with reasonable and proper consideration for the welfare and rights of others as well as other students and for the best interests of this organization.

POLICY AGAINST HARASSMENT, DISCRIMINATION AND RETALIATION
The Davidson Program for Independence (herein referred to as DPI) is committed to providing a work environment that is free of discrimination. In keeping with this commitment, DPI maintains a strict policy prohibiting all forms of unlawful harassment, including sexual harassment and harassment related to an individual's race, ancestry, color, religion, national origin, sex (including gender identity), sexual orientation, marital status, age, disability (physical or mental including HIV/AIDS diagnosis), medical condition (cancer and genetic characteristics), exercising the right to any legally provided leave of absence in the application of any policy, practice, rule or regulation, or other characteristic protected by state or federal law. This policy applies to all clients and staff members of DPI. This policy also applies to visitors and guests of DPI. Furthermore, it prohibits unlawful harassment in any form, including verbal, physical and visual harassment. It also prohibits retaliation of any kind against individuals who file a valid complaint or who assist in a DPI investigation.
Sexual harassment includes, but is not limited to, making unwanted sexual advances and requests for sexual favors where either (1) submission to such conduct is made an explicit or implicit term or condition of participation in DPI; (2) submission to or rejection of such conduct by an individual is used as the basis for decisions affecting such individuals; or (3) such conduct has the purpose or effect of substantially interfering with an individual's performance, or creating an intimidating, hostile or offensive learning environment. Individuals who violate this policy are subject to disciplinary action up to and including the possibility of immediate discharge or removal from DPI.
Unlawful harassment may take many forms, including the following examples of unacceptable behavior:
-Unwanted sexual advances.
-Offering an any benefit in exchange for sexual favors or threatening any detriment (such as discharge or disciplinary action) for a client’s failure to engage in sexual activity.
-Making or threatening reprisals after a negative response to sexual advances.
-Visual conduct, such as leering, making sexual gestures, displaying of sexually suggestive objects or pictures, cartoons or posters.
-Verbal conduct, e.g., making or using derogatory comments, epithets, slurs and jokes.
-Verbal sexual advances, propositions or requests.
-Verbal abuse of a sexual nature, graphic verbal commentaries about an individual's body, sexually degrading words used to describe an individual, suggestive or obscene letters, notes or invitations.
-Physical conduct such as touching, assault, impeding or blocking movements.
-Retaliation for having reported unlawful harassment.
Any DPI client who believes he/she has been harassed or discriminated against should report the incident directly to the Manager of the DPI, or to another person in authority at Wayfinder Family Services with whom the client feels comfortable.
All complaints of harassment that are reported will be investigated as promptly as possible and corrective action will be taken where warranted. All complaints of harassment and discrimination that are reported will be treated with as much confidentiality as possible, consistent with the need to conduct an adequate investigation.
The Manager will investigate all such claims and take appropriate corrective action, including disciplinary action, up to and including immediate discharge, where it is warranted. Clients should feel free to report valid claims without fear of retaliation of any kind. Clients will not be subject to retaliation for registering any complaint of unlawful harassment or discrimination in good faith.

INVESTIGATIVE CONSUMER REPORT DISCLOSURE
Wayfinder Family Services may request, for lawful employment purposes, background information about you from a consumer-reporting agency in connection with your employment or application for employment (including independent contractor assignments, as applicable). Wayfinder Family Services will use the services of an outside consumer-reporting agency to obtain this information in the form of an “investigative consumer report.” An “investigative consumer report” is a background report that includes information from personal interviews (in California, the term includes background reports with or without information obtained from personal interviews), the most common form of which is checking personal or professional references. These reports may be obtained at any time after receipt of your authorization and, if you are hired or engaged by Wayfinder Family Services, throughout your employment or your contract period, as allowed by law. The Company will use this information to evaluate your eligibility for the position sought.
Wayfinder Family Services uses HireRight, Inc. (“HireRight”), a consumer-reporting agency, to prepare or assemble the investigative consumer reports for the Company. HireRight is located and can be contacted by mail at 3349 Michelson Dr. Suite 150 Irvine, CA 92612, and HireRight can be contacted by phone at (866) 521-6995. Information about HireRight’s privacy practices is available at www.hireright.com/Privacy-Policy.aspx.
The investigative consumer report may contain information concerning your character, general reputation, personal characteristics, and mode of living. The types of information that may be obtained include, but are not limited to: social security number verifications; address history; criminal records and history; public court records; driving records; accident history; worker’s compensation claims; educational history verifications (e.g., dates of attendance, degrees obtained); employment history verifications (e.g., dates of employment, salary information, reasons for termination, etc.); personal and professional references checks; professional licensing and certification checks; drug/alcohol testing results, and drug/alcohol history in violation of law and/or company policy; and other information bearing on your character, general reputation, personal characteristics, and mode of living. This information may be obtained from private and public record sources, including, as appropriate: government agencies and courthouses; educational institutions; former employers; personal interviews with sources such as neighbors, friends, former employers and associates; and other information sources.
You have the right to request additional complete and accurate disclosures of the nature and scope of the investigation and may do so upon written request to the Company within a reasonable time after the receipt of this disclosure.
This consent will not affect your ability to question the accuracy of any information contained in a report. If Wayfinder Family Services makes an initial decision to disqualify you based all or in part on your report, you will be provided with a copy of the report and another summary of your rights under the Fair Credit Reporting Act, and if you disagree with the accuracy of the purported disqualifying information in the report, you must notify Wayfinder Family Services within five business days of your receipt of the report that you are challenging the accuracy of such information with the consumer reporting agency, HireRight, Inc.
A summary of your rights under the Fair Credit Reporting Act, as well as certain state-specific notices, are also being provided to you.

ADDITIONAL STATE LAW NOTICE
If you are an applicant, employee or contractor in any of the states listed below, please also note the following:
CALIFORNIA: Pursuant to section 1786.22 of the California Civil Code, you may view the file maintained on you by the consumer reporting agency (e.g., HireRight) during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the costs of duplication services, by appearing at the consumer reporting agency’s offices in person, during normal business hours and on reasonable notice, or by certified mail. You may also receive a summary of the file by telephone, upon submitting proper identification and written request. The consumer-reporting agency has trained personnel available to explain your file to you, including any coded information, and will provide a written explanation of any coded information contained in your file. If you appear in person, one other person may accompany you, provided that person furnish proper identification. “Proper identification” includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. If you cannot identify yourself with such information, the consumer reporting agency may require additional information concerning your employment and personal or family history to verify your identity. Additional California-specific information is set out below.

A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumers reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records).
You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment - or to take another adverse action against you - must tell you, and must give you the name, address, and phone number of the agency that provided the information.
You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
• a person has taken adverse action against you because of information in your credit report.
• you are the victim of identity theft and place a fraud alert in your file.
• your file contains inaccurate information as a result of fraud.
• you are on public assistance.
• you are unemployed but expect to apply for employment within 60 days.

In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.
You have the right to ask for a credit score. Credit scores are numerical summaries of your creditworthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.
You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.
Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.
Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, property owner, or other business. The FCRA specifies those with a valid need for access.
You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.
You may limit "prescreened" offers of credit and insurance you get based on information in your credit report. Unsolicited "prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-567-8688.
You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.
States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For Information about your Federal rights contact:

TYPE OF BUSINESS:
1. a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates.
b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB:
2. To the extent not included in item 1 above:
a. National banks, federal savings associations and federal branches and federal agencies of foreign banks
b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act
c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations
d. Federal Credit Unions
3. Air carriers
4. Creditors Subject to Surface Transportation Board
5. Creditors Subject to Packers and Stockyards Act, 1921
6. Small Business Investment Companies
7. Brokers and Dealers
8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks and Production Credit Associations
9. Retailers, Finance Companies, and All Other Creditors Not Listed Above

CONTACT:
a. Consumer Financial Protection Bureau
1700 G Street NW
Washington, DC 20552
b. Federal Trade Commission:
Consumer Response Center – FCRA
Washington, DC 20580 (877) 382-4357
"a. Office of the Comptroller of the Currency
Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050
b. Federal Reserve Consumer Help Center
PO Box 1200
Minneapolis, MN 55480
c. FDIC Consumer Response Center
1100 Walnut St., Box #11
Kansas City, MO 64106
d. National Credit Union Administration
Office of Consumer Protection (OCP)
Division of Consumer Compliance and Outreach (DCCO) 1775 Duke Street
Alexandria, VA 22314
"Asst. General Counsel for Aviation Enforcement & Proceedings
Aviation Consumer Protection Division
Department of Transportation
1200 New Jersey Avenue, S.E.
Washington, DC 20590
"Office of Proceedings, Surface Transportation Board Department of Transportation
395 E Street, S.W.
Washington, DC 20423
Nearest Packers and Stockyards Administration Area Supervisor
Associate Deputy Administrator for Capital Access United States Small Business Administration
409 Third Street, SW, 8th Floor
Washington, DC 20416
Securities and Exchange Commission 100 F Street, N.E. Washington, DC 20549
Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090
FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center - FCRA Washington, DC 20580 (877) 382-4357

Authorization of Investigative Consumer Report Procurement
I have carefully read and understand the Investigative Consumer Disclosure form. By my signature below, I consent to preparation of an investigative consumer report by HireRight, Inc. (“HireRight”), and to the release of such report to Junior Blind of America (“the Company”) and its designated representatives and agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment (including independent contractor assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if the Company hires me or contracts for my services, my consent will apply, and the Company may, as allowed by law, obtain additional reports pertaining to me throughout my employment or contract period from HireRight and/or other consumer reporting agencies.
I understand that information contained in my employment or contractor application, or otherwise disclosed by me before or during my employment or contract assignment, if any, may be used for the purpose of obtaining and evaluating background reports on me.
I hereby authorize all of the following, without limitation, to disclose information about me to the consumer reporting agency and its agents: law enforcement and all other federal, state and local agencies, learning institutions (including public and private schools, colleges and universities), testing agencies, information service bureaus, credit bureaus (if applicable), record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and all other individuals and sources with any information about or concerning me. The information that can be disclosed to the consumer reporting agency and its agents includes, but is not limited to, information concerning my employment and earnings history, education, motor vehicle history, criminal history, military service, professional credentials and licenses.
I hereby acknowledge that I have carefully read and understand disclosure and this authorization form and hereby agree to their terms. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for any background reports that may be requested by or on behalf of the Company.

CONSENT FOR RELEASE OF INFORMATION
I authorize Wayfinder Family Services to disclose and exchange medical, psychiatric, psychological, educational, vocational, and social information and records (including drug and/or alcohol treatment) between their facilities and the Department of Rehabilitation. The disclosure of this information is for the purpose of adjustment to blindness training and covers the following types of information:

• Diagnosis
• Discharge Summary
• Treatment Plans
• Progress Notes
• Psychological Testing
• Developmental Data
• Educational/Vocational
• Medication/Medical
• Nursing Notes
• Criminal Background

I release both the State Department of Rehabilitation and Wayfinder Family Services, their employees and agents from liability arising from the release of this information.
This consent is subject to written revocation by the undersigned except to the extent that action has been taken prior to such revocation.
This release is valid for a period of one (1) year from the date of signature.

Background Check
Wayfinder Family Services requires you to disclose information regarding criminal convictions. The existence of a conviction does not necessarily mean that a student will be denied admission to Wayfinder, its programs and/or its housing. Each case will be evaluated on its facts, consistent with Wayfinder policies and state licensing requirements.
You must disclose any instance in any state or country where you were adjudicated guilty or convicted of a felony or misdemeanor, including “no contest” pleas and any convictions that you are currently appealing. You do not need to disclose instances where your conviction was overturned on appeal, expunged, annulled, pardoned, destroyed, erased, impounded, or otherwise ordered by the court to be kept confidential.
Upon acceptance of your application, a background check will be required.