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Abu Bekr Shriners

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Business Name:	Abu Bekr Shriners
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	Abu Bekr Temple was organized in March, 1907, with a nucleus of 30 Nobles living in Sioux City and Since that day over 100 years ago Abu Bekr Temple has grown to include a wide area encompassing much of Western Iowa, 2 counties in NE Nebraska and 2 in SE South Dakota. The dedication of the Masonic Temple at Ninth and Nebraska Streets in 1922 provided Abu Bekr with a lavish home for activities of the Nobles from the widespread area. The Shrine's charitable arm is the Shriners Hospitals for Children, a network of twenty-two hospitals in the United States, Mexico and Canada. It was originally formed to treat young victims of polio, but as that disease was controlled, they broadened their scope. They now deal with orthopedic care, burn treatment, cleft lip and palate care and spinal cord injury rehabilitation. All treatment offered at Shriner's Hospitals for Children is offered without any financial obligation to patients and their families, and there is no requirement for religion, race, or relationship to a Shriner. Patients must be under the age of eighteen and treatable. Shriners Hospitals for Children® is changing lives every day through innovative pediatric specialty care, world-class research and outstanding medical education. The 22 hospitals focus on four specialized areas of care: Orthopedic Care – medical and rehabilitative services for children with congenital deformities and conditions, problems resulting from orthopaedic injuries, and diseases of the neuro musculoskeletal system. Burn Care – treatment for acute and non-acute burn injuries and related scarring, along with physical rehabilitation and emotional support. Spinal Cord Injury – spinal cord injury rehabilitation specifically for children, offering some of the most advanced treatment in the country, with full range of services. Cleft Lip and Palate Care – coordinated, comprehensive multidisciplinary care for children with this condition. CONDITIONS TREATED Arthrogryposis (stiff joints) Arthroscopic Surgery Bow Leg (genu varum) Cerebral Palsy (orthopedic Problems) Clubfoot and Congenital Deformities of Lower Extremities Congenital Deformities of the hand & upper Extremities Hand Deformities Hip Disorders (developmental hip dysplasia) In-Toeing (Tibial torsion, femoral anteversion) Juvenile Rheumatoid Arthritis Knock Knees (genu valgum) Leg Calve Perthes Disease Limb Deficiency & Prosthetics Limb Length Discrepancies Metabolic Bone Disease (rickets, osteogenesis imperfecta ) Neuromuscular Disorders (muscular dystrophy, SMA,CMT) Spinal Abnormalities (scoliosis, kyphosis, lordosis) Specialized Plastic Surgery (birth marks, ear abnormalities, Hairy nevus,scar revision) Spina Bifida / Myelodysplasia Sport injuries & fractures (non-emergent)
Website:	https://abubekr.com/index.html
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	(712) 255-7991
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	View in Google Maps 820 Nebraska St, Sioux City, IA 51105, USA
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Dakota County Community Response

115 E 28^th Street

S Sioux City, NE 68776

712-389-4401

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CLIENT RELEASE OF INFORMATION

I, _________________________________, authorize the release of my information to Dakota County Community Response and their affiliated partner agencies & Coaches.

The below list is not all inclusive. Based on client needs, Dakota County Community Response and its agents/coaches may determine that information may need to be released to other organizations for the purpose of completing tasks or activities that the client may have requested or initiated with their application for assistance.

Partner Agencies: Center for Siouxland, City of South Sioux City, Equus Workforce Solutions, Heartland Counseling Services, Immigrant Legal Center, Nebraska DHHS, Nebraska Legal Aid, NENCAP, Siouxland Community Health Center, South Sioux City Housing Agency, South Sioux City Schools, Unity in Action

UNIVERSAL/TWO-WAY RELEASE

I, _____________________________________ hereby authorize the reciprocal release of information contained in these records between Dakota County Community Response and its partnering agencies.

The purpose for such disclosure is: Assessment, services, and case management for connections to community resources.

WAIVER & RISK AGREEMENT

I, _________________________________, do hereby affirm and acknowledge that I am responsible to be aware of the risks associated with accessing available programs/trainings/financial support provided by Dakota County Community Response, including damage to property belonging to me or to others, injury, illness, or other unforeseen circumstances to myself or others, whether caused by me or by others or by conditions/circumstances within or outside of my control or the control of others. I understand an exhaustive description of potential hazards and risks associated with such activity(ies) is not possible and that unknown or unanticipated hazards or risks may result in injury, illness, or death. If equipment is involved in such activity (ies), I agree to inspect all such equipment before use, ask questions if I do not fully understand how to us and/or operate the equipment, accept all equipment “as is”, and to return all equipment before use that is believed to be damaged or defective.

In consideration of my being provided the opportunity to participate in such activity (ies), I fully and completely assume all hazards and risks associated with such activity (ies) and by signing this Waiver and Risk Agreement, do hereby forever waive any responsibility or liability on the part of and completely release Dakota County Community Response, and its officers, directors, members, employees and agents from any and all claims or liability or damage, known and unknown, now and hereafter existing in connection with my participation in any form whatsoever in such activity (ies).

I have read the foregoing Waiver and Risk Agreement. I fully understand the terms and that I may have given up legal rights by signing this document. I sign it freely and voluntarily with the intent to be bound to the terms of this document. My agreement is binding on me and my heirs, estate, and any other parties who may be able to assert a claim by or through me.

HIPAA DISCLOSURE & RELEASE

I, _______________________________, authorize and understand that I have been made aware of Dakota County Community Response HIPAA privacy practices. As Dakota County Community Response operates in the state of Nebraska, the Department of Health & Human Services (DHHS) monitors HIPAA disclosure for the purpose of rendering & engaging in services. My signature on this form grants access and disclosure to my own personal or children’s PHI (Protected Health Information) for the purpose of completing or rendering services via Dakota County Community Response.

Dakota County Community Response, and its officers, directors, members, employees and agents will be allowed to access my or my children’s PHI at any time after signature of this Release for the purpose of completing my request/application and services based on the application that I submit.

My HIPAA authorization can be revoked at any time by notifying Dakota County Community Response in writing at the above listed address. If I revoke my authorization before services have concluded, Dakota County Community Response may terminate my services due to lack of information or ability to disclose PHI to its officers, directors, members, employees, and agents.

CLIENT DISCLOSURE

By signing below, I understand that I must complete the Community Response Exit Survey. If I do not complete the survey, I may not be able to receive any further assistance from Dakota County Community Response funding. The Community Response Exit Survey will be provided to you at the anticipated last coaching visit and/or within 30‐90 days of enrollment into Community Response.

I have read the foregoing Waiver and Risk Agreement, Client Release of Information & HIPAA Disclosure & Release. I fully understand the terms and that I may have given up legal rights by signing this document. I sign it freely and voluntarily with the intent to be bound to the terms of this document. My agreement is binding on me and my heirs, estate, and any other parties who may be able to assert a claim by or through me.

________________________________________	__________________________________	_____________
Signature of Adult Participant	Name of Adult Participant (printed)	Date

Abu Bekr Shriners

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