ALL EVENTS WAIVER/PERMISSION FORM

ALL EVENTS WAIVER/PERMISSION FORM
Which Organization Is This Waiver Form For?
BY SIGNING THIS FORM, YOU ARE GIVING UP SPECIFIC LEGAL RIGHTS THAT YOU MAY HAVE. PLEASE READ CAREFULLY.
TRANSPORTATION LIABILITY WAIVER
I/(We), Guardian
hereby waive any liability for any injury or damage that may occur arising out of the transportation being provided to me OR my child by YOUTH SOLUTIONS ADS (Culture Shock), HBI or CHURCHUNITED relating to the following work:
YOUTH DEVELOPMENT /OR RELATED WORK, EVENTS & ACTIVITIES
I understand that this waiver shall be binding upon my personal representatives, heirs, assigns, and me forever. I have read all of the above and fully understand its meaning and I have signed this waiver voluntarily.
Participants Name

First NameLast Name
Age:
Guardian's Signature

Clear
Date

MonthDayYear
Date
(Parent/Guardian Signature if participant is a minor)
Parent Email:
example@example.com
Address:
City:
State:
Zip:
Phone:
“Consent for Emergency Treatment
(Your Name), hereby authorize any member of YS
(YOUTH SOLUTIONS ADS) to obtain in their sole discretion any necessary Emergency Medical Services for me or my child while at the event/job site. I hereby waive and otherwise give up any claim I may have against YS (YOUTH SOLUTIONS ADS), its staff, officers, volunteers, employees or network providers for any liability which might arise in the course of their attempt to obtain Emergency Medical Treatment. I also agree to be responsible for any and all charges which might be incurred by any medical or emergency personnel rendering treatment which they deem necessary in caring for me or my child, regardless of whether or not the participant is covered by a Health Insurance Plan.
Your Signature

Clear
Date

MonthDayYear
Date
RELEASE AND WAIVER OF LIABILITY
PLEASE BE ADVISED THAT THIS CONSENT FORM WAIVES SPECIFIC RIGHTS YOU MAY HAVE IN CONNECTION WITH INJURIES OR EVENTS ARISING OUT OF YOUR WORKING FOR

YOUTH SOLUTIONS ADS (Culture Shock), CHURCHUNITED, OR HBI ON VARIOUS JOB SITES.

I understand that I or my child is participating in this program willingly with Youth Solutions at various sites. I understand that the various vendors/sites or volunteers will attempt to make sure working conditions and environment is safe. I understand that despite the volunteer/vendors’ implementation of various procedures to create a safe environment, it is not uncommon for me to possibly be injured while engaging in activities when participating in these events. These injuries might include but are not limited to the following: insect bites, falls, broken/sprained arms, legs, fingers, back, etc.

By my signature below, I acknowledge that I have read this form and that I understand I am Waiving Specific Legal Rights I or my child might otherwise have against YS (YOUTH SOLUTIONS ADS), its agents, employees and assigns which might exist if I were not to sign this form.
Knowing all of these things, it is my desire and intent to Waive any and all causes of actions I or my child might have against YS (YOUTH SOLUTIONS ADS) and its partners, affiliated agents, employees and assigns for any liability whatsoever arising out of my working with /or for YS (YOUTH SOLUTIONS ADS), Culture Shock, ChurchUnited & HBI.
Your Name
(Date)

MonthDayYear
Date
Consent for Program Participation
I give my consent for
Child's Name
to participate in ALL EVENTS. I understand the Youth Solutions ADS, CHURCHUNITED & HBI programs include assigning a Coach (mentor) to my child; and that my child will participate in a variety of activities that involve individual, small and large group interaction, participation in community service projects, attendance at career, community and family involvement events with a focus on exploring careers associated with the residential construction industry.
Release of Information
I hereby authorize sharing the following information between the Youth Solutions ADS’ Programs, ChurchUnited and its HBI Mentoring Program and referring agencies, public and private supportive service providers, corrections agencies, workforce development agencies, and employers. Information may be exchanged either verbally (in person and/or by phone) or in written form. Please check each box to indicate authorization.
Education and training information, including assessment results, copies of diplomas, certificates, transcripts and/or degrees and attendance records to document progress towards education and training goals.Offense information to document compliance with probation and court ordered requirements and to document progress regarding non-offending behaviors while involved in Youth Solutions.Driving record to facilitate employment.Employment history and verification, including job status, wages, hours and information related to performance to document progress towards goals. Note: Consent for this release is desired if the goal is employment, employment retention, acceptance into an apprenticeship program, co-enrollment in an industry or employer post secondary education program, and/or enrollment another employment enhancement programVerification of attendance with behavioral/mental health and/or substance abuse treatment provider to document progress towards goals.Health status, medications and disability information for the purpose of ensuring your child’s health and safety while participating in Youth Solutions & CHURCHUNITED & HBI activities and to make necessary accommodations..Social history data, including family, life skills, and other related information to ensure connections to appropriate supportive services..
Video and Photographic Release
Due to the nature of our projects, program activities may be videotaped and/or photographed for publication purposes and to be shared with others through print, electronic and other forms of non-print media. Refusal to release any or all information will not affect participation in Youth Solutions, C hurchUnited & HBI activities. Consent may be revoked at any time by written notice. Your signature below, verifies that you understand the contents and have received a copy of the Consent and Release of Information Form..
Signature of Member or Mentee*

Clear
Date of Signature

MonthDayYear
Date
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
RDGINC 11 2010

U.S. Department of Justice, Award Number: 2009-JU-FX-0002

YS-Form #010_3-06-2012
Should be Empty:

ALL EVENTS WAIVER/PERMISSION FORM

TRANSPORTATION LIABILITY WAIVER

“Consent for Emergency Treatment

RELEASE AND WAIVER OF LIABILITY

Consent for Program Participation

Release of Information

Video and Photographic Release