Consent and waiver- I understand that Qualitea time requires active participation, and that all program costs are covered by Qualitea time. I Understand that I may contact the Qualitea time facilitator with questions or comments in regards Qualitea time. I understand Qualitea time encourages creative and verbal expression, and that Qualitea Time guidelines provide the foundation for group communication. For effective program facilitation, I authorize the mutual exchange of information regarding my Child’s participation in Qualitea time between the Qualitea time Facilitator and myself as the parent/ guardian of participant.
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.
This authorization may be revoked at any time by submitting a written request to the Qualitea time facilitator via email, text or mail (P.O Box 4716 Los Alamos, NM 87547) I hereby certify this request has been made voluntarily. I release the Los Alamos JJAB, its facilitators, 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 herby give my consent for my child to participate in the above program.