Consent and Waiver - I understand that the program requires an 8 session commitment and that all program costs are covered by the Los Alamos JJAB. I understand that I may contact the JJAB facilitator with questions or comments. I understand that the program encourages creative and verbal expression and that the circle guidelines provide the foundation for circle communication. I understand that this program is completely voluntary and that LA LAB Jiu Jitsu and JJAB are partnering to bring this unique experience. JJAB and LA LAB Jiu Jitsu are separate entities and hold separate responsibility.
For the purpose of effective program facilitation, I authorize the mutual exchange of information regarding my child’s participation in the One Circle between the One Circle facilitator, and LA LAB Jiu Jitsu, Professor Romero, and myself as the parent/guardian of the undersigned child.
All information will remain confidential per the JJAB Privacy Practices, unless I have authorized its exchange, except in the following circumstances: danger of one acting on suicidal or homicidal thoughts, danger of injury to oneself or others, suspected child or vulnerable adult abuse or neglect, or court subpoena. I have received the Notice of JJAB Privacy Practices. This authorization may be revoked at any time by submitting a written request to JJAB Resource Specialist (P.O. Box 4716, White Rock, NM 87547). I hereby certify that this request has been made voluntarily.
I release the Los Alamos Juvenile Justice Advisory Board, its contractors, and its employees, from liability for any claims by me or any third party in connection with the participation of the undersigned minor child. I hereby give my consent for the undersigned child below to participate in the above program.