Urban Champions Employment Application 22-23

AUTHORIZATION OF RELEASE OF INFORMATION AND WAIVER FORM

THIS FORM MUST BE COMPLETED & SIGNED BY THE PARENT OR GUARDIAN
I, the parent or guardian of , (write child's name, if under age 18) do hereby understand that the information given and obtained will be for the sole purpose of providing programs and services by the Greater Cincinnati Urban League and its program partners and volunteers
blank
Please initial the releases for which you give your consent
Media Release: Any reporting to the general public will be generic in nature. I understand that the Greater Cincinnati Urban League (hereinafter referred to as GCUL) or any of the program partners will pay neither my child nor me for pictures and any information obtained for the purpose of promoting the program.*
Liability Waiver: I agree to assume full responsibility for any injuries, damages or loss which my child may sustain as a result of participating in any and all program activities. I further agree to indemnify, defend and hold harmless GCUL and any program partners and volunteers from any and all claims resulting from injuries, damages and losses sustained by my child arising out of, connected with or in any way associated with the activities of the program.*
Release of School Information: I do hereby give my permission to GCUL and any program partners to release or obtain information about my child from any agency of the Board of Education including school data and testing scores.*
School child most recently attended*
Medical Release
I hereby consent to:
1) The administration of any treatment deemed necessary by Dr. (name and phone of preferred physician). 2: the transfer of the child to blank (preferred hospital or to any hospital reasonably accessible).
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
CONSENT

By signing this release and waiver form I affirm and hereby execute on behalf of the participant that I have read and fully understand the competence and validity of this document and warrant that I am a parent or guardian authorized to execute this release and waiver form.
Youth Participant’s Name *

First NameLast Name
Parent/Legal Guardian’s Name *

First NameLast Name
Date*

MonthDayYear
Date
Parent / Legal Guardian Signature*

Clear

Emergency Data Sheet

THIS FORM MUST BE COMPLETED & SIGNED BY THE PARENT OR GUARDIAN
Youth Name*
Date of Birth*

MonthDayYear
Date
Medical condition(s) – Please include allergies, disability and/or diagnosis:*
Please list all current medications--Please include the dose, frequency, and condition medication is taken for*
Will youth be taking medication while at work? (Youth MUST be able to take medication independently; without reminder or monitoring)*

YesNo
Preferred Hospital*
Physician’s Name*

First NameLast Name
Physician’s Phone Number*
Do you have a medical card?*

YesNo
If you have a medical card, which type?*
May staff administer First Aid/CPR?*

YesNo
Does youth participant have a seizure disorder?*

YesNo
If so, date of last seizure?*

MonthDayYear
Date
Emergency Contact Person's Name*

First NameLast Name
Phone Number*
Relationship*
Guardian Name*

First NameLast Name
Phone Number*
Relationship*
I agree to permit staff to provide a copy of this EMERGENCY DATA SHEET for the youth named above, to attending Medical and/or police personnel in the event of a medical emergency. Permission to release this information is granted for the youth named above for the entire duration of the association with the program.
Parent OR Guardian signature: (If participant has guardian, guardian must sign)*

Clear
Date*

MonthDayYear
Date
Staff Witness Signature

Clear
Date

MonthDayYear
Date
If further notification is needed, please contact:
Name

First NameLast Name
Phone Number
Relationship
You are required to be complete this form in order to be eligible.

PARENT OR GUARDIAN CONSENT FORM

(To be completed for Sixteen and Seventeen Year Olds Only)
Full Name of Minor*

First NameMiddle InitialLast Name
Proof of Age (Minor must present a copy of proof of age that can be kept with personnel records). Which type of document will be presented.*
Address of Minor*

Street Address

Street Address Line 2

City, StateState / Province

Zip Code
Date of Birth*

MonthDayYear
Date
Age*
School District in Which Minor Lives*
School Minor Attends*
Name of Parent or Guardian*

First NameLast Name
Relationship to Minor*
Address of Parent or Guardian*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Consent

I hereby certify that to the best of my knowledge and belief, the above statements are true and that the minor named above may work with approval.
Signature of Parent or Guardian*

Clear
Date Signed*

MonthDayYear
Date
Minors aged sixteen and seventeen who are to be employed during summer vacation months after the last day of the school term in the spring and before the last day of the school term in the fall, in non-agricultural and non-hazardous employment as defined by the Fair Labor Standards Act of 1938, 52 Stat. 1060, 29 U.S.C.A. 201, and similar state statutes, or in other employment not prohibited to minors age sixteen and seventeen by law, shall not be required to provide an age and schooling certificate as a condition of employment. In order to be hired for employment during summer vacation months, such minors shall provide the employer with the following:

1) Evidence of proof of age in the same manner as proof of age is provided the superintendent of schools under division C of Section 3331.02 of the Revised Code.

2) A statement signed by the minor’s parent or guardian consenting to the proposed employment during the summer vacation months. For the purpose of this section, in the absence of a parent or guardian, a person over eighteen years of age with whom the minor resides may sign such statement.

The employer shall retain a copy of the proof of age and the statement of consent with the minor’s employment records.
Should be Empty:

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Extremely Low (30%) Income Limits
Very Low (50%) Income Limits
Low (80%) Income Limits

2023 Urban Champions Employment Application

The City of Cincinnati’s Community Development Block Grant Program

Or

Participant Agreement

AUTHORIZATION OF RELEASE OF INFORMATION AND WAIVER FORM

Please initial the releases for which you give your consent

Medical Release

Emergency Data Sheet

PARENT OR GUARDIAN CONSENT FORM

Consent