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 County. Wrap-around services available through this program include (but are not limited to):

• Family Coaching

• 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 a Family 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 * Required
Are you a case manager making a request on behalf of a client * Required
If you heard about us from another program/organization, specify * Required
If you heard about us from a school, specify

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

Parent First Name: * Required

Parent Last Name: * Required

Street Address: * Required

City: * Required

State: * Required

Zip: * Required

Work Phone:

Cell Number: * Required

Parent Birth Day: * Required

Email: * Required

Password for future login: * Required

Gender: * Required
Primary Language: * Required
What is your marital status * Required
What is your ethnicity?
What is your annual income (estimated)? * Required
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
* Required

Number of these adults 62 and over with a disability
* Required

Number of adults ages 18 to 61
* Required

Number of these adults 18 - 61 with a disability
* Required

Number of children ages 5 to 17
* Required

Number of these children 5 - 17 with a disability
* Required

Number of children ages 4 and under
* Required

Number of these children 4 and under with a disability
* Required

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

Coaching Commitment Form

Coaching Session 1: Family Intake Survey (60 mins.)
Coaching Session 2: Family/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 Family 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 * Required
Coaching Commitment Agreement Date * Required

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, the Overtown Youth Center (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: * Required
Media Agreement Date: * Required

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: * Required
Electronic Referral Agreement Date: * Required

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 for program evaluation and quality purposes. The Children's Trust provides funding for the program to operate and follows strict data privacy protections for the information collected.
The Children's Trust Consent Waiver: * Required
The Children's Trust Consent Waiver Date: * Required

OnMed Telehealth Consent * Required
OnMed Telehealth Consent Date * Required

Cick here to read the HIPPA Acknowledgement

HIPPA Acknowledgement * Required
HIPPA Acknowledgement Date * Required

Cick here to read the Notice of Privacy Acknowledgement

Notice of Privacy Acknowledgement * Required
Notice of Privacy Acknowledgement Date * Required

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 County. Wrap-around services available through this program include (but are not limited to): • Family Coaching • 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 a Family 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 * Required Are you a case manager making a request on behalf of a client * Required If you heard about us from another program/organization, specify * Required If you heard about us from a school, specify If you heard about us from a other program/organization, specify Parent First Name: * Required Parent Last Name: * Required Street Address: * Required City: * Required State: * Required Zip: * Required Work Phone: Cell Number: * Required Parent Birth Day: * Required Email: * Required Password for future login: * Required Gender: * Required Primary Language: * Required What is your marital status * Required What is your ethnicity? What is your annual income (estimated)? * Required 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 * Required Number of these adults 62 and over with a disability * Required Number of adults ages 18 to 61 * Required Number of these adults 18 - 61 with a disability * Required Number of children ages 5 to 17 * Required Number of these children 5 - 17 with a disability * Required Number of children ages 4 and under * Required Number of these children 4 and under with a disability * Required Is there anything else you would like to share about your family's well-being or your child(ren)'s education? * Required Coaching Commitment Form Coaching Session 1: Family Intake Survey (60 mins.) Coaching Session 2: Family/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 Family 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 * Required Coaching Commitment Agreement Date * Required 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, the Overtown Youth Center (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: * Required Media Agreement Date: * Required 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: * Required Electronic Referral Agreement Date: * Required 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 for program evaluation and quality purposes. The Children's Trust provides funding for the program to operate and follows strict data privacy protections for the information collected. The Children's Trust Consent Waiver: * Required *The Children's Trust Consent Waiver Date: Required** OnMed Telehealth Consent * Required OnMed Telehealth Consent Date * Required Cick here to read the HIPPA Acknowledgement HIPPA Acknowledgement * Required HIPPA Acknowledgement Date * Required Cick here to read the Notice of Privacy Acknowledgement Notice of Privacy Acknowledgement * Required Notice of Privacy Acknowledgement Date * Required Please leave this checkbox blank