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  • Electronic Authorizations

    Electronic Authorizations

    for Jeffco Prosperity Partners
  • Electronically signing and submitting this application means that:

    • You will verify your identity by validating your email address
    • All information provided by you on the application is true and correct to the best of your knowledge
    • You agree to the use of your electronic signature as well as electronic submission of this application, along with any and all documents uploaded as applicable

    You may opt out of electronic application submission at any time by closing this window as long as you have not clicked on the Submit button (on the last page).  A paper application and the required documentation, if required, may instead be sent to the following address:

    Jefferson Prosperity Partners
    5150 Allison Street
    Arvada, CO 80002

     

  • Adult Family Member Information

    Adult Family Member Information

    (Child members over 21 years: please fill your own separate form as the primary adult. Thank you!)
    •  
    • If you are the primary adult/applicant who is filling out this form for their family (or you -- yourself -- are a child participant who has become 21+), please make sure to put your own personal information here as the 1st adult, doing so while all other adults in your family should be listed as subsequent entries. Thank you!

    •  / /
    • A2 
    •  / /
    • A3 
    •  / /
    • A4 
    •  / /
    • A5 
    •  / /
    • A6 
    •  / /
    •  
    • Child Minor Participant Information

      Child Minor Participant Information

      (20y and Younger)
    • C1 
    •  / /
    • {15to20}

    • {21plus}

    • C2 
    •  / /
    • {15to20}

    • {21plus}

    • C3 
    •  / /
    • {15to20}

    • {21plus}

    • C4 
    •  / /
    • {15to20}

    • {21plus}

    • C5 
    •  / /
    • {15to20}

    • {21plus}

    • C6 
    •  / /
    • {15to20}

    • {21plus}

    • C7 
    •  / /
    • {15to20}

    • {21plus}

    • C8 
    •  / /
    • {15to20}

    • {21plus}

    • C9 
    •  / /
    • {15to20}

    • {21plus}

    •  
  • Household Information

  • Adult 1  :  {fnA1} {lnA1}

    is {ageA1} years old

    since birthday {dobA1}.

    {eaA1}  {mcA1}  {cnA1}

  • Adult 2  :  {fnA2} {lnA2}

    is {ageA2} years old

    since birthday {dobA2}.

    {eaA2}  {mcA2}  {cnA2}

  • Adult 3  :  {fnA3} {lnA3}

    is {ageA3} years old

    since birthday {dobA3}.

    {eaA3}  {mcA3}  {cnA3}

  • Adult 4  :  {fnA4} {lnA4}

    is {ageA4} years old

    since birthday {dobA4}.

    {eaA4}  {mcA4}  {cnA4}

  • Adult 5  :  {fnA5} {lnA5}

    is {ageA5} years old

    since birthday {dobA5}.

    {eaA5}  {mcA5}  {cnA5}

  • Adult 6  :  {fnA6} {lnA6}

    is {ageA6} years old

    since birthday {dobA6}.

    {eaA6}  {mcA6}  {cnA6}

  • Child 1  :  {fnC1} {lnC1}

    is {ageC1} years old

    since birthday {dobC1}.

    School Name:  {snC1}

    {eaC1}  {mcC1}  {cnC1}

  • Child 2  :  {fnC2} {lnC2}

    is {ageC2} years old

    since birthday {dobC2}.

    School Name:  {snC2}

    {eaC2}  {mcC2}  {cnC2}

  • Child 3  :  {fnC3} {lnC3}

    is {ageC3} years old

    since birthday {dobC3}.

    School Name:  {snC3}

    {eaC3}  {mcC3}  {cnC3}

  • Child 4  :  {fnC4} {lnC4}

    is {ageC4} years old

    since birthday {dobC4}.

    School Name:  {snC4}

    {eaC4}  {mcC4}  {cnC4}

  • Child 5  :  {fnC5} {lnC5}

    is {ageC5} years old

    since birthday {dobC5}.

    School Name:  {snC5}

    {eaC5}  {mcC5}  {cnC5}

  • Child 6  :  {fnC6} {lnC6}

    is {ageC6} years old

    since birthday {dobC6}.

    School Name:  {snC6}

    {eaC6}  {mcC6}  {cnC6}

  • Child 7  :  {fnC7} {lnC7}

    is {ageC7} years old

    since birthday {dobC7}.

    School Name:  {snC7}

    {eaC7}  {mcC7}  {cnC7}

  • Child 8  :  {fnC8} {lnC8}

    is {ageC8} years old

    since birthday {dobC8}.

    School Name:  {snC8}

    {eaC8}  {mcC8}  {cnC8}

  • Child 9  :  {fnC9} {lnC9}

    is {ageC9} years old

    since birthday {dobC9}.

    School Name:  {snC9}

    {eaC9}  {mcC9}  {cnC9}

  • AUTHORIZATION TO RELEASE/OBTAIN CONFIDENTIAL INFORMATION

    •  
    • I, {fnA1} {lnA1}, {authCONFIDENTIAL}

    • *PLEASE NOTE:  JPP is a part of the Jefferson County Human Services Department. Enrolling in JPP grants access to your family’s information in the state-run database known as the Colorado Benefits Management System (CBMS). This is the same system you adhere to when applying for any governmental benefits and shares the following information about you and your family: social security numbers, date of birth, address, phone number, and any awarded benefit you or your family have received in the state of Colorado. Your information is stored in a secure database and only employees who are working on providing services to your family are permitted to view your personal information.

    •  
    •  
    •  
    • CONFIDENTIAL sigA2 
    • I, {fnA2} {lnA2}, {authCONFIDENTIAL}

      Electronic Signature:  *   

    •  / / :
    • CONFIDENTIAL sigA3 
    • CONFIDENTIAL sigA4 
    • CONFIDENTIAL sigA5 
    • CONFIDENTIAL sigA6 
    • CONFIDENTIAL sigC1 
    • CONFIDENTIAL sigC2 
    • CONFIDENTIAL sigC3 
    • CONFIDENTIAL sigC4 
    • CONFIDENTIAL sigC5 
    • CONFIDENTIAL sigC6 
    • CONFIDENTIAL sigC7 
    • CONFIDENTIAL sigC8 
    • CONFIDENTIAL sigC9 
    •  
  • AUTHORIZATION FOR TEXT MESSAGES

    •  
    • I, {fnA1} {lnA1}, {authTEXTING}

    •  
    • I, {fnA1} {lnA1}, {authTEXTING}

      Electronic Signature:  *   

    •  / / :
    • TEXTING sigA2 
    • TEXTING sigA3 
    • TEXTING sigA4 
    • TEXTING sigA5 
    • TEXTING sigA6 
    • TEXTING sigC1 
    • TEXTING sigC2 
    • TEXTING sigC3 
    • TEXTING sigC4 
    • TEXTING sigC5 
    • TEXTING sigC6 
    • TEXTING sigC7 
    • TEXTING sigC8 
    • TEXTING sigC9 
    •  
  • AUTHORIZATION FOR PHOTO RELEASE

    •  
    • I, {fnA1} {lnA1}, {authPHOTOGRAPHY}

    • PHOTOGRAPHY sigA2 
    • PHOTOGRAPHY sigA3 
    • PHOTOGRAPHY sigA4 
    • PHOTOGRAPHY sigA5 
    • PHOTOGRAPHY sigA6 
    • PHOTOGRAPHY sigC1 
    • PHOTOGRAPHY sigC2 
    • PHOTOGRAPHY sigC3 
    • PHOTOGRAPHY sigC4 
    • PHOTOGRAPHY sigC5 
    • PHOTOGRAPHY sigC6 
    • PHOTOGRAPHY sigC7 
    • PHOTOGRAPHY sigC8 
    • PHOTOGRAPHY sigC9 
    •  
  • AUTHORIZATION FOR DIRECTORY RELEASE

    Agreement to Participate in Jeffco Prosperity Partners Community Family Contact Directory
  • Jeffco Prosperity Partners Family Advisory Committee developed a tool to facilitate and keep our community connected.  JPP has created a shared document online that will allow for families, who choose to participate, the option to share their personal contact information and a little bit about themselves to connect with families outside of official JPP programming.  

    What is a virtual directory?

    A virtual member directory is a valuable resource for JPP community members. This directory will contain the names and contact information for all the members of community and staff who chose to participate. Information shared will include the following: your name, phone number, email, and a picture that will be shared with all members who chose to participate. 

    **Families can remove their names from this directory at any time, but it is not guaranteed that the information will not be saved or stored with other families once connections have been made. 

    Why participate?

    It provides you an opportunity to get to know other JPP families and contact each other outside of JPP programming. The directory is completely optional and it is a great way to connect, share talents, meet up with other families, engage in fun activities, meet families who share interests or have similar goals , connect over coffee, create play dates, and even share recipes!  The opportunities are endless.

  • SIGNATURE

    •  
    • DIRECTORY sigA2 
    • DIRECTORY sigA3 
    • DIRECTORY sigA4 
    • DIRECTORY sigA5 
    • DIRECTORY sigA6 
    • DIRECTORY sigC1 
    • DIRECTORY sigC2 
    • DIRECTORY sigC3 
    • DIRECTORY sigC4 
    • DIRECTORY sigC5 
    • DIRECTORY sigC6 
    • DIRECTORY sigC7 
    • DIRECTORY sigC8 
    •  
  • JPP Disclosure Statement

  • JPP staff are mandated reporters. A mandatory reporter is defined as a professional who is obligated by law to report known or suspected incidents of child abuse and/or neglect. Mandatory reporters are part of the safety net that protects children and youth and have the ability to provide lifesaving help to child victims in our community. Any person specified in C.R.S. 19-3-304 is by law a mandatory reporter in Colorado. If a mandated reporter has reasonable cause to know or suspect that a child has been subjected to abuse or neglect, or observed the child being subjected to circumstances or conditions that would reasonably result in abuse or neglect, the mandatory reporter shall immediately upon receiving such information report or cause a report to be made of such fact to the county department, the local law enforcement agency, or through the child abuse reporting hotline system (https://www.co4kids.org/mandatoryreporting).
    Other areas of mandatory duty to report are any of the following types of abuse or suspected abuse:

    • Child abuse and/or neglect
    • Elder abuse and/or neglect
    • Threats of Suicide or homicide
    • Threats to harm of buildings, entities, organizations, groups of people or public spaces. 

    JPP adheres to integrity of family voice and confidentiality within the JPP team. Being a part of JPP offers a safe space to tell your story and grow towards your goals. We work very hard to ensure your information is shared on a need to know basis, with the exception of the above mentioned policy.

     

  • SIGNATURE

    •  
    • {fnA1} {lnA1}

      Electronic Signature:  *   

    •  / / :
    •  
    • DISCLOSURE sigA3 
    • DISCLOSURE sigA4 
    • DISCLOSURE sigA5 
    • DISCLOSURE sigA6 
    • DISCLOSURE sigC1 
    • DISCLOSURE sigC2 
    • DISCLOSURE sigC3 
    • DISCLOSURE sigC4 
    • DISCLOSURE sigC5 
    • DISCLOSURE sigC6 
    • DISCLOSURE sigC7 
    • DISCLOSURE sigC8 
    • DISCLOSURE sigC9 
    •  
    • Revocation

    • I , {fnA1} {lnA1} would like to revoke my release of information on    Pick a Date   

      Electronic Signature:    

    • Should be Empty: