I do hereby give my permission for my child to participate in the Know Yourself Social Emotional Project (Youth/Young Adult) Events/Education Recreation Mentoring and Restorative youth services. I understand the purpose of the event/program is for youth to gain recreational life skills, mentoring, and social-emotional information to enhance transition to adulthood and life choices. I consent to my child’s participation in GBPS youth-related activities.
I do hereby give my permission for my child to be photographed while involved in the Know Yourself Social Emotional Project activities. I hereby release and hold harmless all representatives or agents from against any liability arising from the use of any of the photographs taken or portions thereafter. My signature below represents consent for my child’s participation and photographic release.
I assume all risk including any risk associated with any special medical needs or condition of participation in the Know Yourself Social Emotional Project Event/Training for youth. I authorize medical personnel and/or project staff to administer medical care treatment as circumstances require while being involved in the Know Yourself program. I agree to not hold such persons responsible for any damage arising from giving of such consent and agree.
I authorize the disclosure and/or obtainment of information described below to support the treatment and/or recovery support services being provided to me through the GBPS for Prevention and Intervention Services. Description of information to be Disclosed: 1. Copies of the intake and service forms that I have completed. 2. A copy of my service choices. 3. A copy of the information I have provided to locate me for future interviews. The purpose of this disclosure is to improve the continued provision of education, employment, mental health, and social support services with other providers. I understand that I have a right to revoke this authorization at any time by sending a written request. This authorization will expire 24 months following the date of my signature. I understand that the people/ agencies named on this form will not provide to others additional services based on whether or not I give authorization. They have explained to me that failure to sign this authorization may make it difficult to effectively coordinate these services that are provided by multiple organizations and agencies. I understand that I have the right to inspect and copy any information to be disclosed, subject to limitations under law. I understand that State and Federal Laws prohibit the person or organization that receives information about me from making any further disclosure without my express written consent.
