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33Questions
  • 1
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  • 2
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  • 3
    • Friend
    • Parent
    • Relative
    • Teacher
    • Pastor
    • Social worker
    • Internet search
    • Social Media
    • Email Blast
    • Cleveland UMADAOP Website
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  • 4
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  • 5
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  • 6
    Please Select
    • Please Select
    • Male
    • Female
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  • 7
    -
    Pick a Date
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  • 8
    • African American/ Black
    • Caucasian/ White
    • Hispanic/Latino
    • Other
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  • 9
    School or College youth goes to:
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  • 10
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  • 11
    • Both Living
    • Both Deceased
    • Mother Deceased
    • Father Deceased
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  • 12
    Perent or Guardian completing this form
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  • 13
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  • 14
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  • 15
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  • 16
    Please Select
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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  • 17
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  • 18
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  • 19
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  • 20
    • African American/ Black
    • Caucasian/ White
    • Hispanic/Latino
    • Other
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  • 21
    • Full-Time
    • Part-Time
    • Retired
    • Unemployed
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  • 22
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  • 23
    • Asthma
    • Diabetes
    • High Blood Pressure
    • Migraine Headache
    • Epilepsy
    • Drug Use
    • Alcohol Use
    • Sickle Cell Disease
    • Gastro Intestinal Problems
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  • 24
    Please answer yes or no.
    1 of 10
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  • 25
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  • 26
    Please indicate any special dietary needs of your child, answer yes or no.
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  • 27
    Please answer yes or no.
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  • 28
    Please specify any vegetables or meats.
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  • 29
    Please answer yes or no.
    1 of 12
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  • 30
    Please specify any clothing or hair products.
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  • 31
    Please answer yes or no.
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  • 32

    Video/Photo Release

    I, hereby grant and authorize Cleveland UMADAOP the right to take, edit, alter, copy, exhibit, publish, distribute, and make use of any and all videos/photos taken of me to be used for any lawful purpose, and to provide advocacy and support for treatment, prevention, recovery, youth, and reentry services.

    This authorization extends to languages, media, formats, and markets now known or later discovered.

    This authorization shall continue indefinitely unless I otherwise revoke this authorization in writing.

    I waive the right to inspect or approve any finished product in which my likeness appears.

    I agree to this release without being compensated. I waive any right to royalties or other compensation arising or related to the use of the video/photo, understanding that any funds or other resources that may be acquired from this video/photo will be used only for the purpose of supporting further productions, supporting substance use disorder (SUD) programming, to include prevention, treatment, recovery, youth and reentry projects.

    I understand and agree that these materials shall become the property of Cleveland UMADAOP and will not be returned. I understand that Cleveland UMADAOP is a private nonprofit organization, and that there may be times that donations or compensation maybe given in relation to visual, audio, and printed project(s)of which I may volunteer to participate, and I agreed that all such funds that may be collected are solely the possessions of the Agency, unless otherwise set forth in a separate contract between myself and the Agency prior to start of production.

    I hereby hold harmless and release Cleveland UMADAOP from all liability, petitions, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons may make while acting on my behalf, or on behalf of my estate.

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    BY CLICKING YES YOU AGREE TO CLEVELAND UMADAOP VIDEO/PHOTO RELEASE FORM.
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