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  • SHOP Parent/Guardian Permission Form

    Thank you for your interest in the Health Education Council's SHOP Program. Youth and young adults ages 12-24 in the Sacramento, Placer, and Yolo Counties who have been directly affected by untreated mental illness, violence, poverty, homelessness, incarceration, or school failure are eligible to apply. If the youth is under 18 years old, this form must be completed by a parent/guardian.
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  • Life Experience

    In order to provide the best support possible, it is helpful for us to understand the experiences youth have had. We understand that this information is highly personal. The information is only shared with SHOP staff working directly with a youth and is stored in a secured data system.
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  • Permission Form for Photo/ Video/ Filming
    I authorize and give permission that the Health Education Council photograph and video tape or film my child, and I as well, as long as my children participate in the program. I recognize that neither I, nor my children will be compensated by the center or by a third person for the use of the images. I give permission to the Health Education Council to use the images to demonstrate program impact on several social media, including, but not limited to Health Education Council’s website, Facebook, and Instagram pages, the newsletters, and the websites of the Office of Minority Health, Community-Oriented Policing Services, and the Center for Court Innovation.

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  • Youth Participant Pre-Survey

    Please have your child complete this page so we can learn more about them.

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  • Parental Consent & Liability Waiver

  • Participant Permission Form

    I, * , as the parent or legal guardian of * , a minor, hereby give permission for my child to participate in activities related to the SHOP program organized by Health Education Council (HEC). I understand that participation in this program may include, but is not limited to, health youth groups, group discussions, interactive activities, and other events facilitated or supervised by HEC staff and volunteers.

  • 1. Consent for Transportation

    I,    *  , as the parent or legal guardian of     * , a minor, hereby give permission for my child to be transported to and from    by transportation arranged by The Health Education Council (HEC). I understand that transportation may include but is not limited to:

    • Rideshare services (e.g., Uber, Lyft, or similar third-party providers)
    • Commercial or chartered vehicles
    • Public transportation (bus, train, etc.)
    • Vehicles operated by HEC staff, volunteers, or designated representatives.


    2. Assumption of Risk

    I acknowledge that transportation, whether by rideshare, private vehicle, or HEC staff, involves inherent risks, including but not limited to accidents, injuries, vehicle malfunctions, delays, and exposure to unforeseen hazards. I understand that while HEC aims to use reliable and insured transportation options, it cannot guarantee the safety, policies, or actions of third-party providers or drivers.

    I also understand that if my child is transported in a vehicle driven by an HEC staff member or volunteer, HEC ensures that such individuals possess a valid driver’s license and proof of insurance, but I acknowledge that HEC does not assume liability for any accidents, injuries, or incidents that may occur during transportation.

    I voluntarily assume all risks associated with my child’s transportation and agree that my child’s participation is at our own risk.

    3. Release of Liability & Indemnification

    I, on behalf of myself, my child, and our heirs, executors, administrators, and assigns, hereby release, waive, and hold harmless The Health Education Council (HEC), its officers, directors, employees, volunteers, agents, and affiliates from any and all claims, liabilities, damages, losses, or injuries arising out of or in connection with my child’s transportation, including but not limited to personal injury, death, property damage, or financial loss, whether caused by negligence or otherwise.

    I further agree to indemnify and defend HEC against any claims, damages, or expenses, including attorney’s fees, brought by or on behalf of my child related to their participation in the transportation.

    4. Staff & Volunteer Transportation Policy

    I understand that if my child is transported in a vehicle driven by an HEC staff member or volunteer, the following applies:

    • All HEC staff and volunteers must have a valid driver’s license and proof of insurance.
    • HEC does not assume responsibility for staff or volunteer vehicles, including insurance coverage, accidents, or mechanical failures.
    • HEC staff and volunteers are expected to follow all traffic laws and safety protocols but are not liable for unforeseen incidents.
    • At no time will a single staff member transport a minor alone unless prior written consent is provided by the parent/guardian.


    5. Medical Emergency Authorization

    In the event of an emergency during transportation, I authorize HEC staff, volunteers, or transportation providers to seek emergency medical treatment for my child if I cannot be reached. I acknowledge that I am responsible for any medical costs incurred.

    6. Compliance with Transportation Policies

    I understand that:

    • Uber, Lyft, and other rideshare companies prohibit unaccompanied minors from riding unless part of an authorized youth program.
    • If my child is found to be ineligible for a transportation method, alternate arrangements may be required, which could delay transportation or require me to pick up my child.
    • HEC reserves the right to deny transportation to any youth based on safety concerns.


    7. Acknowledgment and Agreement

    I have carefully read this Parental Consent & Liability Waiver and fully understand its terms. I acknowledge that I am signing this waiver voluntarily and with full knowledge of its significance.

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