Acknowledgment of Risk: By signing below, I acknowledge that I am the legal parent or guardian of the minor listed above and give my consent for my child to participate in the Reality Check program. I understand that there are inherent risks involved in any event, and I hereby release St. Peter’s Health Partners, its employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my child’s involvement.

Consent to Transport: By signing below, I agree to give permission to Reality Check staff of St. Peter’s Health Partners to transport my child in a personal automobile, rented vehicle or bus in connection with Reality Check activities and/or an emergency.

The following code of conduct will be enforced at every youth meeting, event, and training that is held for Reality Check. All participants and their parent or guardian must sign this document before the youth can participate in the training.

• All participants agree to listen and follow the directions of the Reality Check/ Youth Engagement Coordinator.
• The possession and or use of weapons, alcoholic beverages, tobacco products, and illegal drugs is prohibited.
• Any sexual contact is prohibited.
• Any behavior that violates any of the laws of the United States, the State of New York, or any local ordinance is prohibited.
• Stealing will not be tolerated.
  Participants will treat others with respect regardless of race, economic status, gender, sexual orientation, or ability.
• Any inappropriate or disruptive behavior, including bullying, cyber-bullying, intimidation, or physical hazing in any form will not be tolerated.
• Any threats made towards another person will be reported to Reality Check Coordinator immediately.
• All participants are to show respect for the property of others and the facility in which events/meetings are held.
• All participants are to remain on site for the duration of the meetings.
• Attendance and punctuality of scheduled activities is strongly encouraged for all participants.

I have read the above Code and reviewed it with my parent/guardian. We understand that if it is determined I have violated the Code my parents will be called to pick me up or provide transportation home for me (at their expense) and I will no longer be able to attend events for Reality Check. The responsibility for making this determination is vested in St. Peter’s Health Partners staff.

I hereby request and consent that my child is permitted to travel to and from and participate in the Reality Check trainings, meetings and activities. I understand the following:

• Trainings are designed as a means to educate and update the New York advocates on the latest techniques in tobacco prevention.
• I agree that no official or employee associated with the training or activity will be held responsible for any injuries or damages occurring while my child is traveling to or from or participating in the training or activity. I do hereby hold harmless the sponsoring agencies, their officials, divisions and agents against any and all liability, damage, loss, claims, or demands, which arise out of or are in any way connected with my child or ward’s participation in the activities or meetings.
• I hereby authorize any official of the training or designated chaperone to consent to emergency medical treatment as necessary for the health and safety of my child. I further agree that no official or volunteer will be held responsible for injuries or damages arising from the provision of any such emergency medical treatment. I do hereby agree to indemnify and hold harmless the sponsoring agencies, their officers, divisions and agents from any and all liability, damage, loss, claims, or demands and actions of any nature whatsoever, including attorney’s fees, which arise out of or are in any way connected with the provision of such emergency medical services. 

I further grant permission for my child to appear in person or in voice, video or photographic presentation for radio, television, websites, or print media reports and/or media campaign(s) resulting from participation in New York State Youth Reality Check activities or events and also to complete confidential or anonymous surveys and participate in interviews for evaluation purposes.

I am the parent or legal guardian for the above-named participant and give my permission for him/her to attend activities sponsored by Reality Check. I hereby certify that the information provided is correct. In the case of a medical emergency, I understand that every effort will be made to contact the emergency contacts listed above. In the event those persons cannot be reached or time does not permit, I hereby give permission to a licensed physician or other licensed medical provider, to provide proper treatment, including but not limited to hospitalization, injection, anesthesia and/or surgery for the above-named participant.

On behalf of myself and my ward/minor, I/we hereby RELEASE, WAIVE and FOREVER DISCHARGE St. Peter’s Health Partners and its officers, directors, employees, parents and subsidiaries, agents, from any and all claims, liabilities, causes of actions, damages, demands, judgments,  executions, liens and costs whatsoever, in law or equity, including, without limitation, liability for death or bodily injuries to any person or damage to any property resulting from any (i) claims made against medical providers of emergency services (who are not employed by St. Peter’s Health Partners) under this authorization, or (ii) against St. Peter’s Health Partners for obtaining medical emergency services for said participant pursuant to this authorization.