Advocacy Support Group Sign up to join our foster and adoptive village This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.Join our village we meet in the following times(Required)(Virtual) First Tuesday of the month: 12-1 p.m.(Virtual) Third Tuesday of the month: 7-8 p.m.(In-person) Third Thursday of the month, St. James library 11 a.m.- 1 p.m.(In-person) Third Saturday of the month at the Laclede County Library from 10 a.m.- 12 p.m.(in-person) Fourth Thursday of the month at the Bethal Fellowship Church in Versailles from 6 -8:30 p.m.Your Name(Required) First Last Your Address(Required) Street Address Address Line 2 City State 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 ZIP Code Your Email Address(Required) Email Address Confirm Email Address Your Phone(Required)Preferred Method of ContactEmailPhoneBest Time to Call You(Required)Select A Time12:00 am12:30 am1:00 am1:30 am2:00 am2:30 am3:00 am3:30 am4:00 am4:30 am5:00 am5:30 am6:00 am6:30 am7:00 am7:30 am8:00 am8:30 am9:00 am9:30 am10:00 am10:30 am11:00 am11:30 am12:00 pm12:30 pm1:00 pm1:30 pm2:00 pm2:30 pm3:00 pm3:30 pm4:00 pm4:30 pm5:00 pm5:30 pm6:00 pm6:30 pm7:00 pm7:30 pm8:00 pm8:30 pm9:00 pm9:30 pm10:00 pm10:30 pm11:00 pm11:30 pmRace/Ethnicity(Required) American Indian or Alaska Native American Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White or Caucasian Multiracial/Other No Preference Are you a foster, guardianship, and/or adoptive caregiver?(Required) Foster Guardianship Adoption Formal (Children’s Division Involvement) or informal (no Children’s Division Involvement) caregiver How many Foster/Guardianship/Adoptive children are in your care? Please specify placement type(Required)CENTRAL MISSOURI FOSTER CARE & ADOPTION ASSOCIATION CONFIDENTIALITY AGREEMENT Policy Respecting the privacy of our clients, their families, staff, and of the organization itself is a basic value of Central Missouri Foster Care and Adoption Association (CMFCAA). Personal and identifiable information is confidential, and what is discussed within the support group setting shall remain confidential. It is the policy of CMFCAA that such information must be kept confidential both during and after the support group has ended. Unauthorized disclosure of confidential or privileged information is a serious violation of this policy and will subject the person(s) who made the unauthorized disclosure to appropriate discipline, including removal/dismissal from the group and all future support groups. Agreement During the time that I participate in support groups with Central Missouri Foster Care & Adoption Association (CMFCAA) I realize that I may gain access to information that is considered to be confidential and intimate to other families. Through support group discussions, sensitive topics will be discussed, which should remain confidential within the group setting at all times. Since confidential information is crucial to the effectiveness of support groups with CMFCAA, and because CMFCAA in some instances has the obligation to protect such information, I agree that I will not use, publish or disclose such information during or after my involvement in a support group. I will preserve the restricted nature of this information except to the extent that it becomes publicly available, or is otherwise lawfully obtained outside the scope of this agreement from third parties. I hereby certify that I have read, understand and agree to Central Missouri Foster Care & Adoption Associations policies as described in this statement, with respect to confidential information and conflict of interest, and that the information given in this statement is complete and accurate to the best of my knowledge.(Required) Yes No Please type your name(s) to serve as your electronic signature for the above Confidentiality Agreement.(Required)Please provide today's date that you signed the agreement.(Required)