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FailSafe-ERA Youth & Family Application

Failsafe-ERA Youth & Family offers a group mentoring program for families affected by incarceration to promote healthy communication and positive relationships.  Individuals learn, in a supportive and non-judgmental environment, the techniques to properly grieve the loss of their incarcerated loved ones and how to survive the incarceration process, the most common being the shame associated with admitting that incarceration has touched their lives.  Through our family support group, we have given family members that were ashamed a voice.  They learn how to manage expectations and how not to become an enabler once the loved one returns home.   Join below.

FailSafe-ERA Youth & Family Application

Area of Residence
Race
White/Caucasian
Black/African American
Asian
Native American/Alaskan
Native Hawaiian/Pacific Islander
Hispanic/Latino
Middle Eastern/North African
Other
Gender
Female
Male
Transgender
Non-Binary
Household Income
Under $20,000
$20,000 to 39,000
$40,000 to 59,000
$60,000 to $79.900
$80,000 to $99.900
$100,000 to $149,9000
$150,000 to $199,999
$200,00 and above
I am impacted by my
My Loved One is
Incarcerated
Released
Are You Interested in the Caring Connections Support Group?
Yes
No
Are You Interested in the Caring Connections Youth Group?
Yes
No

Photo Consent

I hereby consent to the use of photographs/videos taken during the support group activities for publicity, promotional and/or educational purposes (including publications, presentations, broadcast, or other media sources.) I do this with the
Yes, I give my consent for FailSafe-ERA to photograph or video me during Support Group Activities.
No, I do not authorize FailSafe-ERA to photograph or video me during Support Group Activities.

Release & Hold Harmless

I agree to release and hold harmless FailSafe-ERA and its officers, acting officials, and agents from any and all liability, loss, damage, claims, or actions for bodily injury and/or property damage, in accordance with current state and federal law, arising out of participation in this group.

This information collected is for Internal use & Data purposes, FailSafe will not sell nor share your information.

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