ELITE Ambassadors Council CONSENT/CONFIDENTIALITY FORM

1

If this form is for a child under the age of 18, a guardian must complete this section,
I, First Name Last Name attest that I am the parent/legal guardian of Child's First Name Child's Last Name . I agree to allow him/her to participate in the ELITE Ambassadors Council.

Parent/legal guardian's contact information: Area Code Phone Number , Street Address Address Line 2 City State Zip Email , Signature

I agree to the following statements listed below:

2

If you are an adult, over the age of 18, type your name here,
I First Name Last Name agree to the following statements below:

3

PHOTO RELEASE* This field is required.I understand that photos of participants will be taken during meetings and events. I grant the right and permission of photographs taken to be used in your publications including brochures, flyers, social media platforms, website, etc. I release you from any and all claims and demands that may arise out of or in connection with the use of the photographs.

YESNO

4

CONTACT INFORMATION RELEASE * This field is required.I understand and agree to allow sharing my contact information with fellow participants. I understand that I cannot release anyone's contact information without their consent.

YESNO

5

PERMISSION TO RECORD* This field is required. I consent to be recorded during virtual and face-to-face meetings and events.

YESNO

6

ASSURANCE OF CONFIDENTIALITY* This field is required. In order to protect the clients who receive services from Our House & MVSU, I affirm that all correspondence, communications, and information received as relating to any services or referrals shall be held in strictest confidence.

YESNO

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CONFIDENTIALITY* This field is required.I understand that All information shared by participants will remain confidential with the following exceptions: • We suspect that a minor child is being abused. In such a case, we will contact Child Protective Services. • We witness through sight or hearing an imminent physical assault or unlawful/dangerous act upon you by another person. In such case, we may contact law enforcement for assistance. • We learn or have reason to believe that you intend to harm yourself. In such case, we may notify law enforcement and or emergency medical personnel to seek assistance for you. • We learn or have reason to believe that you intend to harm another person and have the means and ability to do so. In such case we may contact law enforcement and/or may warn the person who you intend to harm. • If you give us written or verbal permission to release information to others, we will do so in accordance with the terms of that permission. You will have the right to revoke that permission at any time.

YESNO

8

RELEASE OF LIABILITY* This field is required. I understand and agree that Our House, Inc. shall not be responsible for any losses of personal property, or for any bodily injuries or the results thereof, incurred and suffered by me in connection with any travel and/or activities sponsored by Our House, Inc.

YESNO

9

AUTHORITY AND CONSENT TO THE PROVISION OF EMERGENCY MEDICAL SERVICE* This field is required. If I need medial attention while at any activity held at Our House & MVSU or other sites; while traveling via Our House vans, rental transportation or staff's personal vehicle, I authorize Our House & MVSU staff to seek and consent to emergency medical care on my behalf, if necessary, until I or an immediate family member has been contacted and are in direct communication with emergency personnel. I understand that Our House does not employ medical personnel to administer medical assistance. I agree to hold Our House & MVSU and their staff harmless and agree and understand that neither will be legally liable for exercising the authority to consent to emergency medical care that I am consenting to above.

YESNO

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PARENT/LEGAL GUARDIAN SIGNATURE Signature

SIGNATURE OF ELITE PARTICIPANT UNDER THE AGE OF 18 Signature

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SIGNATURE OF ELITE PARTICIPANT, AGE 18+ Signature

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Date of Signature* This field is required.This document expires 1 year after date of signature.

Date

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