Registration and Informed Consent for Participation

Registration and Informed Consent for Participation
Please select which group the youth will be participating in*

Girls Empowerment GroupBirds of a FeatherGame ChangersYAS or YAS TooMindful Creations
Youth Information
Youth Name*
Youth Preferred Name
Youth Pronouns
Age*
Caregiver Information
Caregiver Name*
Address*

Address

Street Address Line 2

City/TownState / Province

Postal / Zip Code
State*
Zip Code*
Phone Number*
Email Address*
example@example.com
Email Group Consent*

I would like to be added to a Caregiver email groupI do not want to be added to a Caregiver email group
I acknowledge that I can terminate or modify this consent at any time. I will give the group facilitators written notice of my wish to modify or terminate all or any portion of this consent. I understand that OPC is not responsible for any of my personal expenses associated with communicating via electronic messaging or email. By agreeing to be added to the email group, I recognize that electronic communications present risk and are not completely private. I realize that computer hackers can invade email with viruses. I understand that emails may be misdirected, intercepted, or forwarded to unintended recipients. I understand the risks associated with using email.
Youth & Caregiver Group Consent
Youth Signature*

Clear
Date of Signature

MonthDayYear
Date
Caregiver Signature*

Clear
Date of Signature

MonthDayYear
Date

Consent To Photograph/Videotape
Youth Name:*
Caregiver Name:*
Please Choose from the Options Below:*

I consent for myself/my child to be photographed videotaped during their participation in the group.I Do Not consent for myself/my child to be photographed videotaped during their participation in the group.
I consent to the following Use/Disclosures*

Use of Photos/Video for sharing of Outcomes/Mission Moments with OPC’s Board of TrusteesAdvocacy, Marketing or public relations materials developed by OPCAdvocacy, Marketing or public relations materials developed by outside media outletsUse on the OPC Website or Social Media
I understand that:

1.       I may refuse to sign this authorization and that it is strictly voluntary.

2.       I may revoke this authorization at any time in writing but if I do, it will not have any effect on any actions taken prior to receiving the revocation

3.       A copy of this Photo Release is available to me and/or my child upon request

I understand that, in the instance of external sources (such as media outlets, newspapers, advocacy groups), Ocean Partnership for Children, Inc. is acting only as the intermediary, making it possible for the aforementioned source(s) to contact me. As such, I relieve and hereby agree to hold Ocean Partnership for Children, Inc. free and harmless from any and all liability arising out of the use and/or release of information; interview; photograph/ videotape/film; and subsequent publication or broadcast. I understand that the interview(s) or photo session(s) are being carried out upon my consent and authorization and so assume full responsibility.
Choose One*

This authorization does not expire.This authorization expires (enter date below)
This authorization expires on*
Youth Signature*

Clear
Date of Signature

MonthDayYear
Date
Caregiver Signature*

Clear
Date of Signature

MonthDayYear
Date

Group Behavioral Contract
Youth's Name:*
Caregiver's Name:*
I agree to the following guidelines of Group:
1. I will keep my hands and objects (including all technology/battery operated devices) to myself to keep everyone safe.
2. I will refrain from bullying other participants. This includes, but is not limited to: during group, social media, school, bus and or any other places in community.
3. I will refrain from sharing or disclosing content shared by participants and maintain a judgment free environment.
4. I will make sure to follow facilitator instructions/directions including not leaving the group premises without permission from Facilitators and remaining within eyesight of facilitators.
5. Adhering to Words To Live By (this will be created on first day of group).
I understandthat failure to adhere to the Group guidelines can result in my immediate dismissalfrom participation with the group.
Youth Signature*

Clear
Caregiver Signature*

Clear
Should be Empty:

Registration and Informed Consent for Participation

Youth Information

Caregiver Information

Youth & Caregiver Group Consent

Consent To Photograph/Videotape

Group Behavioral Contract