EDEN Application

EDEN Place Enrollment Application

The Overtown Youth Center (OYC) EDEN Place Family Resource Center offers wrap-around services and supports to students and their families in Miami-Dade and Broward Counties. Wrap-around services available through this program include (but are not limited to):

• Family Coaching
• Assistance navigating healthcare resources and services
• Access to health education workshops and services (e.g., nutrition, fitness, and chronic illness prevention/management)

• Information and referrals for community resources

• Assistance in school meetings

• Linkage to academic support/tutoring services

• Parenting and financial wellness workshops

• Resources to meet household needs (e.g., childcare, food, housing, and transportation)

• Employment assistance and/or job training

• Clothing assistance through the Neat Stuff Program

Participation in this program will involve an Intake Meeting, creation of a Household Success Plan, and follow up meetings/communications throughout program participation.

If you are only interest in assistance through Neat Stuff at this time please indicate
Are you a case manager making a request on behalf of a client
If you heard about us from another program/organization, specify
If you heard about us from a school, specify

If you heard about us from a other program/organization, specify

Adult First Name:

Adult Last Name:

Street Address:

City:

State:

Zip:

Work Phone:

Cell Number:

Parent Birth Day:

Email:

Password for future login:

Gender:
Primary Language:
What is your marital status
What is your ethnicity?
What is your annual income (estimated)?
What is the highest level of education attainment in your household?

Please tell us about your household (including yourself)

Number of adults ages 62 and over

Number of these adults 62 and over with a disability

Number of adults ages 18 to 61

Number of these adults 18 - 61 with a disability

Number of children ages 5 to 17

Number of these children 5 - 17 with a disability

Number of children ages 4 and under

Number of these children 4 and under with a disability

Is there anything else you would like to share about your family's well-being or your child(ren)'s education?

Health and Wellness

The following questions help OYC better understand your family's health and wellness needs and connect you to supportive resources and services.

Parent: Do you currently have a primary care physician?
Does the Child(ren) have a primary care physician?

Do you currently have health or wellness concerns for yourself or your child(ren)? * Required
Would you be interested in participating in health and wellness workshops or educational sessions through OYC? * Required

Coaching Commitment Form

Coaching Session 1: Intake Survey (60 mins.)
Coaching Session 2: Household Success plan (30-60 mins.)
Coaching Session 3: Follow-up (30 mins.)
Coaching Session 4: Follow-up (30 mins.)
Coaching Session 5: Follow-up (30 mins.)

The program includes a Intake Meeting, Household Success Plan, and follow-ups. Goals should be specific, measurable, achievable, relevant, and time-bound. Families are encouraged to maintain an ongoing relationship with OYC staff and attend meetings, except in cases of illness or emergencies.
Coaching Commitment Agreement
Coaching Commitment Agreement Date

If you are refusing services, please specify reason:

Many parents/adults enjoy seeing pictures of their children or themselves in the newspaper, on television, or on social media; however, some parents/adults do not want their images shared publicly for various reasons. If you do not want yourself or your child photographed,(OYC Miami) will make an extra effort to see that you or your child is not available to public media sources. Realistically, all situations cannot be controlled, and OYC Miami cannot guarantee that an adult or child will not be identified in the public media reports, etc.

Please indicate your preference below:

Media Agreement:
Media Agreement Date:

OYC may use electronic systems (such as UniteUS) to submit referrals on behalf of clients to other community agencies or providers. Staff will share referral recommendations with clients prior to sending any information to another agency. Please indicate if you agree to have your information shared through this referral process.

Electronic Referral Agreement:
Electronic Referral Agreement Date:

As part of my voluntary participation in this program, I give my permission for the information collected through this program to be submitted to The Children's Trust or other relevant funders for program evaluation and quality purposes. These organizations provide funding for the program to operate and follows strict data privacy protections for the information collected.
Data Sharing Consent Waiver:
Data Sharing Consent Waiver Date:

OnMed Telehealth Consent
OnMed Telehealth Consent Date

Cick here to read the HIPPA Acknowledgement

HIPPA Acknowledgement
HIPPA Acknowledgement Date

Cick here to read the Notice of Privacy Acknowledgement

Notice of Privacy Acknowledgement
Notice of Privacy Acknowledgement Date

Please leave this checkbox blank


EDEN Place Enrollment Application The Overtown Youth Center (OYC) EDEN Place Family Resource Center offers wrap-around services and supports to students and their families in Miami-Dade and Broward Counties. Wrap-around services available through this program include (but are not limited to): • Family Coaching • Assistance navigating healthcare resources and services • Access to health education workshops and services (e.g., nutrition, fitness, and chronic illness prevention/management) • Information and referrals for community resources • Assistance in school meetings • Linkage to academic support/tutoring services • Parenting and financial wellness workshops • Resources to meet household needs (e.g., childcare, food, housing, and transportation) • Employment assistance and/or job training • Clothing assistance through the Neat Stuff Program Participation in this program will involve an Intake Meeting, creation of a Household Success Plan, and follow up meetings/communications throughout program participation. If you are only interest in assistance through Neat Stuff at this time please indicate Are you a case manager making a request on behalf of a client If you heard about us from another program/organization, specify If you heard about us from a school, specify If you heard about us from a other program/organization, specify Adult First Name: Adult Last Name: Street Address: City: State: Zip: Work Phone: Cell Number: Parent Birth Day: Email: Password for future login: Gender: Primary Language: What is your marital status What is your ethnicity? What is your annual income (estimated)? What is the highest level of education attainment in your household? Please tell us about your household (including yourself) Number of adults ages 62 and over Number of these adults 62 and over with a disability Number of adults ages 18 to 61 Number of these adults 18 - 61 with a disability Number of children ages 5 to 17 Number of these children 5 - 17 with a disability Number of children ages 4 and under Number of these children 4 and under with a disability Is there anything else you would like to share about your family's well-being or your child(ren)'s education? Health and Wellness The following questions help OYC better understand your family's health and wellness needs and connect you to supportive resources and services. Parent: Do you currently have a primary care physician? Does the Child(ren) have a primary care physician? Do you currently have health or wellness concerns for yourself or your child(ren)? * Required Would you be interested in participating in health and wellness workshops or educational sessions through OYC? * Required Coaching Commitment Form Coaching Session 1: Intake Survey (60 mins.) Coaching Session 2: Household Success plan (30-60 mins.) Coaching Session 3: Follow-up (30 mins.) Coaching Session 4: Follow-up (30 mins.) Coaching Session 5: Follow-up (30 mins.) The program includes a Intake Meeting, Household Success Plan, and follow-ups. Goals should be specific, measurable, achievable, relevant, and time-bound. Families are encouraged to maintain an ongoing relationship with OYC staff and attend meetings, except in cases of illness or emergencies. Coaching Commitment Agreement Coaching Commitment Agreement Date If you are refusing services, please specify reason: Many parents/adults enjoy seeing pictures of their children or themselves in the newspaper, on television, or on social media; however, some parents/adults do not want their images shared publicly for various reasons. If you do not want yourself or your child photographed,(OYC Miami) will make an extra effort to see that you or your child is not available to public media sources. Realistically, all situations cannot be controlled, and OYC Miami cannot guarantee that an adult or child will not be identified in the public media reports, etc. Please indicate your preference below: Media Agreement: Media Agreement Date: OYC may use electronic systems (such as UniteUS) to submit referrals on behalf of clients to other community agencies or providers. Staff will share referral recommendations with clients prior to sending any information to another agency. Please indicate if you agree to have your information shared through this referral process. Electronic Referral Agreement: Electronic Referral Agreement Date: As part of my voluntary participation in this program, I give my permission for the information collected through this program to be submitted to The Children's Trust or other relevant funders for program evaluation and quality purposes. These organizations provide funding for the program to operate and follows strict data privacy protections for the information collected. Data Sharing Consent Waiver: Data Sharing Consent Waiver Date: OnMed Telehealth Consent OnMed Telehealth Consent Date Cick here to read the HIPPA Acknowledgement HIPPA Acknowledgement HIPPA Acknowledgement Date Cick here to read the Notice of Privacy Acknowledgement Notice of Privacy Acknowledgement Notice of Privacy Acknowledgement Date Please leave this checkbox blank