Release of Liability, Agreement, And Consent of Parent or Guardian of Minor

 PLEASE READ THIS DOCUMENT COMPLETELY BEFORE SIGNING. ITS EFFECT IS TO RELEASE PARTNERS FROM ANY LIABILITY RESULTING IN YOUR CHILD/WARD'S PARTICIPATION IN PARTNERS' MENTORING PROGRAM AND WAIVES ALL CLAIMS FOR DAMAGES OR LOSSES AGAINST PARTNERS AND ITS AFFILIATED ORGANIZATIONS

As parent or guardian of the child, represent to Partners that I have the authority to give permission and release liability for any mental, emotional, or physical injuries and/or death that might occur to said child while participating in the Partners' program.

I hereby acknowledge that my child/ward is voluntarily participating in the Partners' mentoring program and activities offered by Partners as a part of that program. I agree to abide by all applicable rules of the program and I have instructed my child/ward to follow the rules of the program.

I understand that there are inherent risks of my child participating in the Partners program and voluntarily, with knowledge of the risk involved, agree to accept all liability. These risks include but are not limited to: traveling to and from Partners-related activities; injuries that occur while participating in mentoring activities; and any injuries arising out of the one-to-one contact with my child's/ward's Senior Partner and/or Case Manager. I understand that there may be other risks either not fully known to me or readily foreseeable at this time; and I fully accept and assume all such risks and all responsibility for losses, cost and damages I incur as a result of the participation of my child/ward in the Partners program.

As lawful consideration for my child/ward being allowed to participate in the Partners' mentoring program, I agree that I or anyone representing myself or my child/ward will not make a claim against, sue, or attach the property of Partners of Mesa County, Partners Inc. or any of its affiliate organizations for injury or damage resulting from negligence or other acts however caused, by any volunteer, employee, agent or contractor of Partners or its affiliates as a result of my child/ward's participation in Partners' mentoring activities/programs. In addition, I hereby release, waive, discharge and/or otherwise indemnify Partners and its affiliated organizations, sponsors, employees and volunteers from all actions, claims or demand by or on behalf of myself and/or my child/ward as a result of participation in the Partners program or activities and/or being transported to and from the same, to the full extent permitted by law.

I hereby give my permission for any picture of my child/ward to be used anytime by Partners for the purpose(s) of recruiting and/or public relations.

I give permission for Partners or the Partners representative to share and access information with other agencies including the referral agency and any professional persons working with my child/ward, including but not limited to psychological, medical, educational information, professional opinions, and test results. I authorize Partners to disclose such information to any third party who Partners believe has a need to know the information involved, including but not limited to a potential Senior Partner. I also understand that Partners cannot guarantee the confidentiality of such information, given the number of participants involved and the openness and configuration of the Partners office. Accordingly, I waive and release Partners from the liability stemming from the unintentional disclosure of said information to any third person.

I authorize the release to Partners of court/police records pertaining to my child/ward, on the condition that such information only be used to assist the Senior Partner in working with my child/ward, and that such information be kept confidential and not become part of any public record except for statistical purposes.

I understand that on special occasions, a Senior Partner may invite any child that I have guardianship of to accompany them on an activity. By signing this release, I give my permission for this to occur. All clauses in this release form shall apply to any and all children under my guardianship who accompany the Senior Partner. Any child who is not in my guardianship cannot participate in activities with the Senior Partner unless the child’s guardian gives expressed consent.

I understand and agree that any legal dispute arising out of my child's/ward's participation in the Partners program and/or arising out of Partners-related activities shall be subject to and governed by the laws of the State of Colorado and venue for any such legal dispute shall be in the proper County or District Court located in the State of Colorado.

*Partners Mentoring Services Effectiveness Index: Informed Consent for Parent/ Guardian

*Virtual Mentoring Consent

I understand that the virtual mentoring sessions will take place under the guidance, parameters and direction of the Case Manager, Mentor and Caregivers. This might include e-mail, Facetime, video, or Google Hangout as examples. We encourage no social interaction be allowed via social media outlets such as Facebook, Twitter, Instagram, Snapchat, or similar platforms. Please be sure to monitor online communications. Should any issues, challenges or concerns arise during virtual mentoring, / and/or my child will refer to the Case Manager for resolution immediately.

Emergency Medical Consent 

I give consent for the Senior Partner or the Partners representative to obtain appropriate emergency medical or dental attention for the child, if such attention is required while I am unavailable for contact. I also understand that I should have in place appropriate health insurance coverage for my child/ward in the event that he or she is injured as a result of his/her participation in the Partners program.

School-Based Mentoring

*Release/Receive Information:

I hereby authorize the release of school records and grade information to Mesa County Partners. By email, Classlink, ParentVUE/StudentVUE. IEP or personal contact regarding my child.

*Transportation Release:

I hereby authorize Mesa County Partners staff to transport my child(ren) To off campus sites to get lunch and other mentoring activities and to return them to their school.

I HAVE CAREFULLY READ THIS AGREEMENT, I FULLY UNDERSTAND ITS CONTENTS AND I HAVE SIGNED IT OF MY OWN FREE WILL.

Insurance Information for Parents/Guardians

Parents and guardians sometimes ask whether their children are protected by any kind of insurance if they are injured while participating in the Partners' program. First, you should know that injuries to children participating in the Partners program are very rare. The safety of children participating in the program is a top priority for Partners' staff. Partners has a very thorough screening process for Senior Partners and Activity Volunteers, and the staff also make every effort to plan fun but safe events for persons participating in the program. Nevertheless, Partners acknowledges that you, as a parent/guardian, have a right to know that your child has some protection while participating in the program. Therefore, Partners is providing you with following information about the insurance protection which may be available to your child if he or she does happen to get injured during a mentoring-related activity. First, in the event that an injury does occur during a Partners' activity, Partners has an accident policy which pays a limited amount for medical treatment needed as a result of the injury. Partners also maintains a policy of liability insurance that provides some protection to the youth in the program. Generally speaking, the liability insurance policy provides coverage for an injury caused by the negligence of Partners' staff, a Senior Partner or an Activity Volunteer during the course of a Partners' mentoring-relating activity. A mentoring-related activity includes the one-on-one time a Junior Partner spends with a Senior Partner, as long as it does not involve one of the specifically excluded activities discussed below.

Senior Partners and Activity Volunteers are required to maintain automobile liability insurance coverage in order to participate in the Partners program (it is also required by Colorado law Partner's liability insurance also provides coverage if a child is injured in an automobile accident while driving with a staff member, Senior Partner or Activity Volunteer to or from a mentoring-related activity. Partners also encourages its Senior Partners and Activity Volunteers to maintain homeowners' or renters insurance, which may provide some insurance protection in the event their negligence causes injury toa child participating in the Partners' program. In all situations (including automobile accidents), the liability insurance maintained by Partners is a secondary insurance policy that, if ever necessary, is only triggered after any other insurance (such as personal liability insurance maintained by a Senior Partner or Activity Volunteer) is applied.

However, there are certain activities for which Partners' liability insurer specifically excludes coverage. These designated "high risk" activities currently include the following:

White Water Rafting

Bouldering

Bungee Jumping

Equestrian

Fencing

Martial Arts

Parachuting Rock

Climbing

Scuba Diving

Sky Diving

Air Shows

Rifle Range

Out of Bounds or Back Country Skiing

Snowmobiling

Surfing

High Ropes/Climbing Towers

Trampolines

Water Skiing/Wakeboarding/Water Tubing

Rodeo Events (as a Participant)

Partners' staff is aware of these specific insurance exclusions and creates the activity schedule in accordance with these limitations. If Partners organizes an event that includes one of the above types of activities, it means that Partners has made arrangements with their insurance carrier for coverage for that event. Or you will be notified that this event is not covered and will be required to sign a special waiver for your child to participate in the activity. However, Partners' insurance does not provide protection if a child participates in any of these types of activities with a Senior Partner or other volunteer outside of an organized Partners' event. Thus, you should be aware of this limitation if your child participates in such an activity during one-to-one mentoring time with a Senior Partner.

There are also some other limitations to Partners' insurance coverage which you should know. For instance, it only covers injuries caused by negligence; it does not cover injuries caused by willful and wanton conduct on the part of any volunteer or Senior Partner. Also, it does not provide protection if an injury occurs outside of the United States. Again, these have never been problems in the Partners' program previously and are not very likely to be an issue in the future.

Also, in this day and age, parents are often concerned about instances of sexual abuse and misconduct. Therefore, you should also know that Partners takes this issue very seriously and makes every effort to prevent this problem through its rigorous screening and matching process and its supervision of Partners' organized events. Parents or Guardians can help prevent such abuse from occurring to their child by talking with their children and urging them to be careful and to report any instances of inappropriate behavior. In the event an accusation does arise, Partners will immediately notify the appropriate authorities for a full investigation and the Partnership will be terminated immediately.

Of course, you can also help protect your child by maintaining health insurance, if at all possible, as well as by encouraging your child to be careful and to use common sense while participating in the mentoring-related activities. Hopefully this letter has answered some of your questions about these issues. You are always welcome to talk with a Partners Case Manager if you have additional questions or concerns.

I hereby acknowledge that I have received and read the above insurance information

In order to best serve your family and provide appropriate services, it is sometimes necessary for agencies and other professional persons to share past, present and future information with each other. We, therefore, request your permission for relevant past, present, and future information to be shared among the agencies and other professional persons listed below if it should be beneficial to do so. Information sharing will be kept to the minimum necessary for the rendering of services.

If you object to the sharing of information with any specific agency listed below, please enter it below then initial the change you have made. Thank you for your cooperation.

This consent form has been explained to me, and / understand that it shall remain in effect until / cancel it in writing.

Partners Health Assessment Form

This form is used for the purpose of gathering helpful information about the child's health. Please answer the following questions to the best of your knowledge. If you have any questions, please contact the Partners Case Manager.

Mentee's Name: Date of Birth: Approximate date of last doctor's exam: Approximate date of last dental exam:

Parent/Guardian Name: Parent/Guardian Phone #(s Mailing Address:

Eligibility Documentation for Partners Mentoring Program

Dear Parents/Guardians,

Mesa County Partners is required by the Department of Human Services to obtain the following information from all program participants for funding purposes. The information provided to Mesa County Partners by the use of this form is confidential. Mesa County Partners appreciates your cooperation on this matter.

By signing this form, you are affirming that the above information is true and correct to the best of your knowledge.