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MEMORANDUM OF UNDERSTANDING
between
ORANGE COUNTY HOUSING AUTHORITY , a public housing authority established under California Health & Safety Code section 34200 and operationally organized under the Orange County Community Resources Department , ANAHEIM HOUSING
AUTHORITY, GARDEN GROVE HOUSING AUTHORITY , SANTA ANA HOUSING
AUTHORITY
and
ORANGE COUNTY HEALTH AUTHORITY dba CALOPTIMA HEALTH
This Memorandum of Understanding (“MOU”) is entered into by and between the Orange County Health Authority, a public agency doing business as CalOptima Health (“CalOptima”), Orange County Housing Authority, Anaheim Housing Authority, Garden Grove Housing Authority, and Santa Ana Housing Authority (each public housing authority is individually referred to as “PHA” and collectively “PHAs”). Each PHA and CalOptima may each be referred to individually as a “Party” and collectively as the “Parties”.
I. BACKGROUND
CalOptima is a public agency that provides health care coverage for Orange County residents who are eligible for Medi -Cal. In January 2022, the Department of Health Care Services ( “DHCS”) launched the California Advancing and Innovating Medi -Cal (“CalAIM”) initiative. CalOptima participates in CalAIM, which seeks to improve quality of life and health outcomes of the Medi- Cal population by leveraging Medi-Cal as a tool to address many complex challenges facing California’s most vulnerable residents, includin g those facing housing insecurity and instability.
Two specific initiatives within CalAIM are Enhanced Care Management (“ECM”) and Community Supports. CalOptima has committed to offering all 14 Community Supports and expanding its provider network accordingly. These Community Supports services are directed at supporting some of the most vulnerable populations in Orange County , including those experiencing homelessness, older adults , children with complex care needs, and those involved with the justice system.
As local public housing authorities, each PHA, among other things, administers federally funded programs to provide rental assistance to qualified tenants in privately owned rental housing. Each PHA administers the Housing Choice Voucher ( “HCV”) program , as well as Special Purpose Voucher (“SPV”) programs such as the Emergency Housing Voucher program, Stability Voucher program, Mainstream Voucher program, Veterans Affairs Supportive Housing, Non-Elderly Disabled program, Family Unification program, and Foster Youth to Independence program.
Participants and applicants (“Participants”) in the HCV program and SPV programs may use rental assistance in a variety of rental dwellings with property owners willing to part icipate in the program. Each PHA desires to help connect certain Participants to support services offered by CalOptima pursuant to a duly executed written consent form provided by its Participants.
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II. PURPOSE
This MOU establish es a referral framework from each PHA to CalOptima for HCV and SPV program Participants to leverage the ECM and Community Support services provided through CalAIM. This MOU affirms the PHAs’ and CalOptima’s roles and responsibilities regarding the referral relationships and provides the framework for each PHA’s referral program and sharing of information. This MOU provide s for, among other things, the disclosure of information to CalOptima, in accordance with the CalAIM Housing and Health Services Voluntary Consent Form to Release, Share, and Disclose Confidential Information , attached as Exhibit A to this MOU. The information will include the minimum necessary to confirm the enrollment of a PHA program Participant in CalOptima’s Medi-Cal program . This information may include, for example, full name, date of birth, and social security number.
III. TERM
This MOU becomes effective upon the last d ate the Parties execute this MOU on the signature page (“Effective Date”) and remains in effect until terminated under Section XI.
IV. POPULATION TO BE SERVED
This MOU applies to a ny household member(s) who holds or is applying to hold a HCV or SPV issued by a PHA and are voluntarily interested in, or already enrolled in, CalOptima’s Medi-Cal program and consent to provide their information to CalOptima by executing the “CalAIM Housing and Health Services Voluntary Consent Form to Release , Share, and Disclose Confidential Information .”
This may include:
• HCV or SPV applicants who have an active application in process of eligibility that has been pulled off of a waiting list for an HCV or SPV; • HCV or SPV applicants who are waiting to be pulled off of a waiting list so long as they provide their written consent;
• HCV or SPV Participants in the Project-Based Voucher program; or • Any other category of HCV or SPV applicant or participant not already listed who may be served by a PHA.
V. SCOPE OF CALOPTIMA SERVICES
A. Once CalOptima receive s information from a PHA of: (i) an individual or family (household) member with a n HCV or SPV (or who is waiting to receive their HCV or SPV); and (ii) who has provided written consent to share their information with CalOptima, by executing the CalAIM Housing and Health Services Vol untary Consent Form to Release, Share, and Disclose Confidential Information attached as Exhibit A , CalOptima shall follow this process:
1. If the individual or household member is unsure of their Medi -Cal status, CalOptima shall either:
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a. Confirm Medi-Cal enrollment; or
b. If the individual or household member is not enrolled in Medi -Cal, refer the individual or household member to the Orange County Social Services Agency (“SSA”) for potential Medi-Cal enrollment.
2. Pursuant to an already existing enrollment . CalOptima staff shall make reasonable efforts to contact all such enrollees to assess for eligib ility for ECM and Community Supports services. If eligible, and interested, CalOptima will make appropriate referrals for services. CalOptima shall make reasonable efforts to monitor ECM and Community Supports services provided to individuals or household members to ensure they are beneficial.
B. CalOptima shall provide aggregate data to each PHA regarding Medi-Cal eligibility and service delivery referrals under this MOU.
C. CalOptima will contract with CalAIM providers to provide Community Support and ECM services, as required under CalAIM. In addition to ECM services, those Community Support services include, but are not limited to (as further described and defined under CalAIM):
1. Housing transition navigation services;
2. Housing deposits;
3. Housing tenancy and sustaining services;
4. Short-term post-hospitalization housing;
5. Recuperative care;
6. Respite services;
7. Day habilitation services;
8. Asthma remediation;
9. Medically tailored meals/medically-supportive food;
10. Community transition services/nursing facility transition to a home;
11. Personal care and homemaker services;
12. Environmental accessibility adaptations (home modifications); and
13. Nursing facility transition/diversion to assisted living facilities, such as Residential Care facilities for elderly and adult residential facilities.
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D. CalOptima shall provide oversight and monitoring of its contracted CalAIM providers and manage all CalAIM providers that perform services under this MOU .
VI. SCOPE OF SERVICES TO BE PROVIDED BY EACH PHA
A. From among its population of HCV and SPV program Participants, each PHA will:
1. Request the voluntary written interest and consent of the program applicant or participant to register for Medi -Cal or their current enrollment status in Medi-Cal in order to gain access to the benefits available to the applicant or participant through CalAIM. Each PHA may make its request for voluntary written interest and consent , at any time, for an HCV or SPV holder.
2. Request written consent to disclose applicant or participant information, or other related information, to CalOptima so that the applicant or participant may access CalAIM benefits. Each PHA shall use reasonable efforts to make this request at least once in writing duri ng the eligibility process for issuance of an HCV or SPV.
3. Request written voluntary interest and consent from Participants to release information to CalOptima, including to the CalAIM providers contracted by CalOptima, as provided in Exhibit A.
B. For those HCV and SPV recipients who voluntary provide written interest and consent under Section IV .A (Population To Be Served) in order to disclose their information to CalOptima for CalAIM purposes, each PHA will:
1. Share the minimum information necessary to confirm the program applicant or participant’s enrollment in CalOptima’s Medi -Cal program . This information may be shared electronically in a secure system , via transfer of a physical form signed by the applicant or participant, or via another method agreed upon by the Parties that complies with applicable laws .
C. Pursuant to the HCV and SPV program regulations found at 24 CFR Parts 5 and 982, each PHA will:
1. Issue vouchers for Participants to search for appropriate rental housing (if a voucher has not already been issued ).
2. Administer and provide the applicant or participant with monthly rental assistance in accordance with the regulations in 24 CFR Part 982 by providing housing assistance payments on behalf of the participant to the applicable landlord.
VII. COMMUNICATION
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During the term of this MOU , each PHA and CalOptima will remain in contact as necessary to effectuate the purpose of this MOU . Each Party will communicate with its mutual Participants in accordance with applicable government agency requirements, policies and procedures. Each PHA and CalOptima will meet as needed to review services described in this MOU . Primary point of contacts will b e assigned by each PHA and CalOptima. CalOptima’s point of contact will be within the CalAIM team.
VIII. COLLABORATION
Each PHA and CalOptima will work together to ensure that individuals and household members who receive services under this MOU are given the opportunity to be referred to CalOptima for appropriate follow-up if they are interested in or are already enrolled in Medi-Cal. Each PHA and CalOptima shall use reasonable efforts to ensure that the disclosure of Participant information from a PHA to CalOptima is performed pursuant to an executed CalAIM Housing and Health Services Voluntary Consent Form to Release, Share, and Disclose Confidential Information , as provided in Exhibit A . CalOptima shall implement procedures to ensure that it only accepts Participant information from a PHA for Participants who have provided written consent to share their information with CalOptima, by executing the CalAIM Housing and Health Services Volu ntary Consent Form to Release, Share, and Disclose Confidential Information attached as Exhibit A.
Each Party agrees to meet as needed to address the following:
A. Funding opportunities;
B. Federal regulations, agency policies and compliance; C. Program operations, procedures, and logistics; and
D. Participant needs and challenges.
IX. RECORDS RETENTION
Each PHA and CalOptima will retain all records related to this MOU for at least three (3) years from the date of inactivity of services or for such longer periods as required by law .
X. CONFIDENTIALITY
A. Each PHA and CalOptima agree to maintain the confidentiality , privacy, and security of all applicant, participant, and tenant records and information pursuant to all applicable federal and state laws and regulations, including without limitation, U.S. Privacy Act of 1974 and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), including interpretive case la w, as may now exist or be hereafter amended , to the extent applicable . For the sake of clarity, none of the PHAs are covered entities, as that term is defined and used under the HIPAA and its implementing regulations , and none of the PHAs are CalOptima’s business associate, as that term is used in HIPAA and its implementing regulations . All information that a PHA discloses under this MOU shall be considered and kept confidential by CalOptima, CalOptima’s contracted Medi -Cal providers, and Cal - Optima’s employees, agents, staff, and volunteers.
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B. Parties further agree that any breach of confidentiality or privacy concerning any applicant, participant, and/or tenant records related to this MOU shall be addressed pursuant to applicable law and each Party’s internal compliance program, as amended from time to time.
C. The Parties shall require all staff, agents, employees , volunteers, vendors, contractors, and/or subcontractors with access to a n applicant’s, participant’s, or tenant’s information to maintain the confidentiality of any and all applicant, participant, and tenant records and information with w hich they may come into contact, as required by law.
D. The Parties ’ confidentiality obligations herein shall survive termination or expiration of this MOU for any reason.
XI. TERMINATION OF MOU
A PHA may terminate its participation in, and obligations under, this MOU with or without cause by providing thirty (30) days’ written notice to the other Parties. A PHA’s termination of participation in this MOU shall not terminate this MOU in its entiret y, but it sha ll terminate the MOU with respect to the PHA that terminates its participation hereunder . If all PHAs terminate their participation in this MOU, either individually or collectively , this MOU shall be terminated in its entirety. In addition, CalOptima may terminate this MOU with or without cause by providing thirty (30) days’ written notice to all participating PHAs prior to the effective date of termination .
Except as provided otherwise hereunder, exercise by any PHA of the right to terminate participation in this MOU shall relieve the PHA of all further obligations under this MOU upon termination, except for those provisions that survive termination as stated herein . Except as provided otherwise hereun der, termination of this MOU shall relieve all Parties of all further obligations under this MOU upon termination, except for those provisions that survive termination as stated herein.
XII. GENERAL PROVISIONS
A. No change, modification, extension, or waiver of this MOU shall be effective unless in writing and signed by all Parties. If any law, rule, or regulation applicable to this MOU, or any interpretation thereof by any court, is modified or implemented during the term of the MOU in a way that materially changes the terms of the MOU (“Regulatory Change ”), CalOptima may, upon written notice to PHA s, propose an amendment of the MOU to PHAs to the minimum degree necessary to comply with the Regulatory Change . If any PHA does not accept the proposed Regulatory Change, CalOptima may immediately terminate this MOU upon written notice to PHAs. This MOU represents the entire understanding of the Parties with respect to the subject matter herein and supersedes all prior agreements a nd understandings, whether written or oral, between the Parties concerning such terms .
B. If any provision of this MOU is held invalid or unenforceable by any court of law, the remaining provisions of this MOU shall nevertheless continue to be valid and enforceable as though the invalid or unenforceable parts had not been included herein.
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C. A PHA may not assign or delegate any obligations or rights under this MOU without the prior written consent of CalOptima.
D. This MOU shall be governed by the laws of the State of California, and the Parties consent to venue and personal jurisdiction over them in Superior Court in Orange County, California, and in U.S. District Court for the Central District of California, as applicable , for purposes of construction and enforcement of this MOU. The Parties shall comply with all applicable laws in performance of their obligations under this MOU.
E. Each Party warrants that it has the full right, power, and authority to enter into and fully perform its obligations under this MOU and that the execution, delivery, and performance of this MOU by that Party does not conflict with any other agreement to which it is a Party or by which it is bound.
F. Each Party has had the opportunity to have counsel of its choice examine the provisions of this MOU, and no implication shall be drawn against any Party by virtue of the drafting of this MOU.
G. This MOU may be executed in multiple counterparts, each of which shall be deemed an original and all of which toget her shall be deemed one and the same instrument.
H. If the Parties are unable to informally resolve any dispute arising out of or relating to this MOU, a Party, with the concurrence of all other Parties, may submit the dispute for resolution exclusively through confidential, binding arbitration, instead of through trial by court or jury, in Orange County, California, in accordance with the commercial dispute rules then in effect of the Judicial Arbitration and Mediation Services (“JAMS”). The arbitration shall be conducted on an expedited basis by a single arbitrator. In making decisions about discovery and case management, it is the Parties’ express agreement and intent that the arbitrator at all times pro mote efficiency without denying any Party the ability to present relevant evidence. In reaching and issuing decisions, the arbitrator shall have no jurisdiction to make errors of law and/or legal reasoning. In the event arbitration is mutually agreed to, the Parties shall share the costs of arbitration equally, and each Party shall bear its own attorneys’ fees and costs.
I. CalOptima agrees to indemnify, defend, and hold harmless each PHA and its elected and appointed officials, officers, employees, and agents and those special districts and agencies for which County of Orange’s Board of Supervisors acts as the governing Board from any third-party claims, demands, including defense costs, or liability of any kind or nature, including, but not limited to, personal injury or property damage, arising from or related to Cal Optima’s failure to perform its obligations under this MOU, gross negligence or intentional misconduct .
J. Each PHA agrees to indemnify, defend, and hold C alOptima, its elected and appointed officials, officers, employees, agents, directors, members, and/or EXHIBIT 1
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affiliates harmless from any third-party claims, demands, including defense costs, or liability of any kind or na ture, including, but not limited to, personal injury or property damage, arising from or related to that PHA’s failure to perform its obligations under this MOU, gross negligence or intentional misconduct .
K. If judgment is entered against one Party by a cour t of competent jurisdiction because of the concurrent active negligence of the other Party or its officials, officers, directors, employees, or agents , the Parties agree that liability will be apportioned as determined by the court.
L. Each Party represents and warrants that the person executing this MOU on behalf of its organization is an authorized agent who has actual authority to bind its organization to each and every term, condition, and obligation of this MOU and that all requirements have been fulfilled to provide such actual authority.
M. Nothing herein contained shall be construed as creating the relationship of employer and employee, or principal and agent, between a PHA and any applicant or participant participating in this program, CalOptima, or any of CalOptima’s agents or employees.
N. This MOU may be executed in two or more counterparts, each of which shall be deemed an original and all of which together shall constitute the same agreement.
Facsimile, documents executed, scanned, and tran smitted electronically, and electronic signatures shall be deemed original signatures for purposes of this MOU, with such facsimile, scanned, and electronic signatures having the same legal effect as original signatures.
XIII. SECURITY
A. The Parties agree to maintain the confidentiality of all information and records shared as a result of this MOU pursuant to all applicable laws relating to privacy and confidentiality that currently exist or exist at any time during the term of this MOU. The Parties represent , warrant, and covenant that they have implemented and will maintain during the term of this MOU administrative, physical, and technical safeguards to reasonably protect private and confidential Participant information, to protect against anticipated threats to the security or integrity of data, and to protect against unauthorized physical or electronic access to or use of data.
Such safeguards and controls shall include at a minimum:
1. Storage of confidential paper files that ensures rec ords are secured, handled, transported, and destroyed in a manner that prevents unauthorized access.
2. Control of access to physical and electronic records to ensure data is accessed only by individuals with a need to know for the delivery of MOU services.
3. Control to prevent unauthorized access and to prevent employees of the Party from providing data to unauthorized individuals.
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4. Firewall protection.
5. Use of encryption methods of electronic data while in transit from the Parties ’ networks to external ne tworks, when applicable.
6. Measures to securely store all data, including, but not be limited to, encryption at rest and multiple levels of authentication and measures , to ensure data shall not be altered or corrupted by third parties . The Parties further re present and warrant that they have implemented and will maintain during the term of this MOU administrative, technical, and physical safeguards and controls consistent with state and federal security requirements.
B. At termination of this MOU and the records retention period required herein , whichever is later, if feasible, the Parties shall return or destroy all information received from the other Part ies. If such return or destruction is not feasible, the Parties shall extend the protections of this MOU to the information and limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible.
XIV. SECURITY BREACH NOTIFICATION
A. All Parties shall have policies and procedures in place for the effective management of Security Breaches, as defined below. In the event of any actual, attempted, suspected, threatened, or reasonably foreseeable circumstance CalOptima or a PHA experiences or learns of that either compromises or could reasonably be expected to comprise C alOptima or PHA data through unauthorized use, disclosure, or acquisition of C alOptima or PHA data ( “Security Breach ”), the Party that has identified the potential Security Breach shall notify the other Party of its discovery within twenty four (24) hours . After such notification, the Party that has identified the potential Security Breach of the other Parties’ data shall, at its own expense, promptly:
1. Investigate to determine the nature and extent of the Security Breach ;
2. Contain the incident by taking necessary action, including, but not limited to, attempting to recover records, revoking access, and/or correcting weaknesses in security; and
3. Report to the other Party the nature of the Security Breach, the data used or disclosed, the person who made the unauthorized use or received the unauthorized disclosure, what has been done or will be done to mitigate any harmful effect of th e unauthorized use or disclosure, and the corrective action that has been taken or will be taken to prevent future similar unauthorized use or disclosure.
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but are not limited to: notifications; investigation and remediation costs, including notification of all whose personal information was disclosed; outside investigation; forensics; counsel; crisis management; and credit monitoring. In the event the Party, whose data has been breached, determines that additional action(s) are required, the other Party shall be ar the reasonable costs to remedy the breach . In the event the Party, whose data has been breached, conducts additional actions(s) arising out of or in connection with a Security Breach, the other Party shall reimburse the Party, whose data has been breach ed, for costs associated to legally required actions.
XV. NOTICES
A. All notices required by this MOU shall be submitted to the addresses in this section. Any notice not related to termination of this MOU may be submitted electronically to the address set forth below.
Orange County Housing Authority
1501 E St. Andrew Place
Santa Ana, CA 92705
Anaheim Housing Authority
201 S Anaheim Boulevard
Suite 201, 2nd Floor
P.O. Box 3222
Anaheim, CA 92803-9987
Garden Grove Housing Authority
12966 Euclid St, Suite 150
Garden Grove 92840
Santa Ana Housing Authority
20 Civic Center Plaza
Santa Ana, CA 92701
CalOptima:
Attn: Contracting Department - Director of Contracting
505 City Parkway West
Orange, CA 92868
Email:
B. All mailed notices shall be deemed effective when in writing and deposited in the United States mail, first class, postage prepaid and addressed as above.
[signature pages follow]
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In Witness Whereof, the Parties have signed this by their duly authorized representatives, effective as of the Effective Date.
CALOPTIMA HEALTH
Signature
Yunkyung Kim
Chief Operating Officer
Date
APPROVED AS TO FORM
[insert entity]
By: ______________________________
[insert title]
Date: _____________________
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ORANGE COUNTY HOUSING AUTHORITY
ORANGE COUNTY COMMUNITY RESOURCES
Signature
Julia Bidwell
Print Name
Executive Director
Title
Date
Approved as to Form:
Office of the County Counsel
Orange County, California
John Cleveland, County Counsel Date
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ANAHEIM HOUSING AUTHORITY
Signature
Grace Stepter
____________
Print Name
Executive Director
Title
Date
Approved as to Form:
Ryan Hodge, Deputy City Attorney Date
ATTEST:
By:
City Clerk
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GARDEN GROVE HOUSING AUTHORITY
Signature
Lisa Kim
Print Name
Executive Director
Title
Date
Attest:
Secretary Date
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SANTA ANA HOUSING AUTHORITY
Signature
Michael L. Garcia
______
Print Name
Executive Director
______
Title
Date
Approved as to Form:
Jose Montoya, Assistant City Attorney Date
ATTEST:
By:
Jennifer Hall, Recording Secretary
10/19/2023
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Exhibit A
CalAIM Housing and Health Services
Voluntary Consent Form to Release, Share, and Disclose Confidential Information
Orange County Health Authority dba CalOptima Health is a public agency that provides health care coverage for Orange County residents who a re eligible for Medi -Cal. CalOptima Health is working alongside the [insert Public Housing Authority name] (Housing Authority) to ensure that any interested housing choice or special purpose voucher applicants/participants are not only enrolled for Medi-Cal, if eligible, but also, receiving any and all benefits that they are eligible for and interested in receiving, including ava ilable housing navigation opportunities.
By signing below, I voluntarily agree to allow the Housing Authority to disclose to CalOptima Health the minimum information necessary about me to confirm enrollment in Medi -Cal and provide the services described herein, including confidential information and personally identifying information ,1 for the following purposes:
1. To determine my current enrollment status in Medi -Cal or my interest in registering for Medi-Cal.
2. To aid me in accessing the benefits available through CalAIM, 2 including case management, and assist in providing temporary and or/permanent housing opportunities.
3. To assist in making referrals for various health care benefits, including, but not limited to, CalAIM Enhanced Care Management and Community Supports. 3
4. To monitor the services, I receive to ensure they are beneficial.
By signing below, I further acknowledge and agree that CalOptima Health may contract with third party Medi -Cal providers to provide services to me . For purposes of this form, CalOptima’s contracted Medi-Cal providers include providers that perform the following categories of services:
CalAIM Enhanced Care Management and Community Supports . I understan d, agree, and authorize Housing Authority and CalOptima to disclose information about me for the purposes described above. Please note that the list of CalOptima’s contracted Medi -Cal providers can change frequently and without notice, and therefore the website should be consulted for the most recent list: https://www.caloptima.org/en/ForMembers/Medi -Cal/FindAProvider. This Voluntary
1 For example, this information may include full name, date of birth, social security number and contact information to assist in coordinating Medi-Cal related benefits or CalOptima services.
2 CalAIM is the California Advancing and Innovating Medi-Cal initiative, which the California Department of Health Care Services launched to improve quality of life and health outcom es for the Medi-Cal population by using Medi -Cal as a tool to address challenges facing Medi -Cal members. CalOptima, as a Medi -Cal health plan, participates in CalAIM and assists its Medi-Cal members in obtaining benefits under CalAIM.
3 These services may include: housing transition navigation services, housing deposits, housing tenancy and sustaining services, short-term post-hospitalization housing, recuperative care, respite services, day habilitation services, asthma remediation, medically tailored me als/medically-supportive food, community transition services/nursing facility transition to a home, personal care and homemaker services, environmental accessibility adaptations, and nursing facility transition/diversion to assisted living facilities such as residential care facilities for elderly and adult residential facilities. CalOptima will assist you in determining for which CalAIM services you are eligible.
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Consent Form is effective on the date provided below. Unless otherwise revoked earlier in writing, this authorization expires five (5) years after the date you sign.
I understand that I may terminate this Voluntary Consent Form at any time by submitting a written notice to the Housing Authority. Termination of this Voluntary Consent Form will not apply to information that was shared under this Voluntary Consent Form prior to its termination.
I confirm that I have read the preceding information, agree to its contents, and have re ceived a copy of this form. I also understand that signing this form is voluntary and that I am not required to sign this form. Treatment, payment, or eligibility for benefits provided by the Housing Authority, CalOptima, and CalOptima’s contracted Medi-Cal providers will not be affected if I do not sign this form. Any questions that I may have had have been answered fully and to my satisfaction. I am the individual indicated below, the individual’s legal representative, or am otherwise authorized by the individual to sign the below and accept these terms on their behalf. If I am not the individual, I understand and agree that any references to “I”, “you”, or “my” are deemed to include the individual.
Head of Household or Legal Representative (Print Full Legal Name) Signature Date
Home Address City State Zip Code
Email Address Date of Birth Telephone number
Co-Head/Other Adult or Legal Representative (Print Full Legal Name)
Signature Date
Email Address Date of Birth Telephone number
Other Adult or Legal Representative (Print Full Legal Name)
Signature Date
Email Address Date of Birth Telephone number
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Other Adult or Legal Representative (Print Full Legal Name)
Signature Date
Email Address Date of Birth Telephone number
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