Informed Consent & Indemnity Form

Informed Consent & Indemnity Form

Youth GO! Programme, a programme by Care Corner Children and Youth Services (CC CYS)
About Us

Care Corner Youth GO! Programme is a street outreach programme for young people aged 12 to 21 years. Our centre is located at 943 Tampines Ave 5 #01-271, (S)520943. Our programmes and services may include befriending, case management, referral to other services, interest-based activities, group activities and outings.

As part of the programme, personal particulars will be collected for accountability, insurance purposes (e.g., outings, competition), applications for services, and surveys may be conducted to better understand the needs of the young persons. We seek your support in completing this form.
Personal Particulars of Child/Ward (Youth) and Parent/ Legal Guardian
Full Name of Youth*
(as in BC/NRIC)
NRIC/FIN of Youth*
Full Name of Parent/ Legal Guardian*
(as in BC/NRIC)
Relationship with Youth*
Parent/ Legal Guardian Contact*
Mobile Number
Youth Contact*
Mobile Number
Street Address*
Postal Code*
1. Medical Declaration
I declare that all the information provided below is true. The young person has no medical condition which might have the effect of making it more likely that he/she be involved in an incident which could result in injury to himself/herself or others.

Medical History of Youth*

	Yes	No	If Yes, please provide details
Have you ever had chest pain, high blood pressure or heart problems?
Have you ever had asthma, bronchitis, tuberculosis, sinus or other lung problems?
Have you ever had fits, epilepsy, fainting attacks, migraine, severe head injury?
Have you ever had eye/ear problems?
Have you ever had a nervous illness?
Have you ever had diabetes?
Have you ever had bone or joint injury?
Have you ever had a carrier status for any infectious disease?
Have you ever had medical treatment within the last two years (major operation, diagnosed health concerns etc.)?
Do you require routine medication?
Do you require a special diet (due to health concerns)?
Do you have any disability?
Any other information to note?

2. PDPA

By providing my details, I consent to release my/ my child’s/ my ward’s personal data to Care Corner Children and Youth Services for the purpose of provision of services, research, and evaluation. I understand that the agency will manage the information appropriately according to Care Corner’s Privacy Policy (https://www.carecorner.org.sg/privacy-policy/) in accordance with the Personal Data Protection Act (PDPA). I further understand that I can withdraw consent at any point and it may affect Care Corner Children and Youth Services from continuing to provide services to me/ my child/ my ward.

3. LIMITED CONFIDENTIALITY

I understand that all information I provided is kept in confidential record, with the following exceptions:
1. When the social worker/ youth worker makes an assessment of a foreseeable suicide or serious self-harm risk;
2. When the young person acknowledges ongoing instances of incest, rape, abuse of a child, elder, or disabled person;
3. When the young person reveals his/her intention to commit a crime or when he/she can be accurately assessed as being a danger to self, others or society;
4. When the information is required by the police, court and/or the Ministry of Social and Family Development (MSF);
5. When the social worker/youth worker, in his/her discretion, has to share general information with the school or other related agencies/authorities.
I have read the preceding statement and understand that under the above-stated circumstances confidentiality is superseded. I understand that in such instances the centre is bound ethically and legally to inform the proper authorities.

4. RISK ACKNOWLEDGEMENT & DISCLAIMER

I understand that the activities may consist of substantial and physical testing. I accept there is a risk of injury to me/my child/ward when undertaking such activities. I acknowledge that Care Corner will not be responsible for the safety of me/my child/ward named above and the safety of their possessions while they are undertaking the activities.

I understand that full co-operation with Care Corner and compliance with all safety systems, guidelines and regulations as set out is required. l shall therefore not hold Care Corner and/or any of the event’s direct or indirect sponsors, responsible for any direct or indirect loss or damage of property or any injury, illness or loss of life which may be sustained by me/my child/ward during the activities or arising from any cause or in connection with the activities, where such damage to or loss of property or any injury or loss of life is not caused by the negligence or wilful act or omission of Care Corner and/or any of the event’s direct or indirect sponsors.

5. VIDEO/AUDIO RECORDING AND TAKING OF PHOTOGRAPHS

I/We hereby give consent for me/ my child/ ward to be interviewed, video/audio recorded and photographs taken for the purpose of: (a) Assessment, training, learning purposes, and/or research; (b) Promoting of services offered by the Centre and/or any other Care Corner centres so as to create more awareness of services being offered by the Centre and/or Care Corner centres which is for the benefit of the community; (c) Applying and attaining of funding and/or subsidy support (where applicable) to support the Centre’s or other Care Corner centre’s operations and programmes. I /We understand that the information and content of the video/audio recording and/or photographed material may be used by the Centre, or any Care Corner centre, or any third-party who has been commissioned by the Centre or other Care Corner centre. In consenting to have the video/audio recording and photographs taken, I/We hereby further give my/our consent to Care Corner to edit and publish the photographs and/or video/audio recordings through print (e.g. newsletters, annual report, brochures, etc.) and non-print mediums (e.g. website, social media) for the purposes mentioned in (a) to (c) above. I/We understand that the video/audio recordings and/or photographs taken may be retained by the Centre or Care Corner Singapore for legal or business purposes in which retention may be necessary, and for the purposes stated in (a) to (c).

6. AUDIO TRANSCRIPTION OF SESSION NOTES

The Agency will be using an automatic speech recognition system for the purpose of audio transcription of the sessions held. The transcription is targeted to capture the dialogue of the individuals in the sessions, as well as to generate a concise summary of the key agendas discussed. Audio records will be erased after 7 days systematically.

I/We hereby give consent for me/ my child/ ward to the Agency’s use of the above-mentioned system, I/we understand and consent to the data collected from the audio transcripts to be processed as mentioned in the other clauses in the Informed Consent Form. The data will be subject to the same confidentiality and exception clauses as mentioned in section [3. Limited Confidentiality.]

I/We understand that my personal data may be stored or processed using cloud services hosted within Singapore. I noted that the Agency is committed to ensuring the transparent handling of my personal data. This encompasses clear communication regarding the use and management of my data, including any significant processing or storage practices that could impact my/our privacy.

7. MSF Data Consent
i. I understand that the Government of Singapore (“Government”) , Participating Agencies and their volunteers require my Personal Information for the following purposes:(a) to determine my and my Family’s eligibility for the Services and Schemes;(b) to provide me and my Family with the Services and Schemes;(c) for data analysis, evaluation and policy-making; and(d) to contact me and my Family for participation in research and/or programmes. 2. I allow the Government, Participating Agencies and their volunteers to collect, share and use my Personal Information for the purposes in Paragraph 1. I understand that my Personal Information will not be shared with non-participating agencies or organisations. 3. My consent remains valid until I withdraw it in writing. I accept that a withdrawal of consent will take 7 working days to effect from the date it is received by the Government. 4. I have read and understood this consent form fully, including the attached Terms of Consent. I declare that the information that I have provided is accurate.

Terms of Consent

I. I understand and agree that these phrases used in the consent form have the following definitions:

a) “Personal Information” includes my:

i) personal data (e.g. name, NRIC No, address, contact details, age, gender, family/household structure);

ii) financial data (e.g. income, insurance coverage);

iii) consumption data (e.g. housing, healthcare bills, scheme subscriptions);

iv) social assistance data (e.g. social assistance history, assessments for eligibility and suitability for social services and public assistance schemes, social worker case reports, assessment(s) by social workers, psychologists and/or other professionals)

v) information relating to assessments of my physical, mental or emotional well-being (e.g. assessments by social workers, psychologists or other professionals), counselling records and records of intervention or any other information relating to services that I am receiving/ have received that are aimed at improving my well-being;

vi) education data (e.g. school, childcare, kindergarten records); employment data, vocational training data; National Service data; and any other information relating to any work (whether paid or unpaid), training or other similar programmes that I may have performed or undergone;

vii) other information (e.g. savings, payment for utilities) provided by me for the evaluation and administration of social services and public assistance schemes.

Personal Information may relate to past, present or future matters.

b) “Family” refers to anyone related to me by blood, marriage (including step-children and in-laws) or legal adoption, whether or not they live together with me.’

c) “Services and Schemes” refer to social services and public assistance schemes, such as the following:

i. healthcare, aged care, childcare, foster care, residential care, welfare services relating to a child/young person[1], child protection, protection of vulnerable adult(s), rehabilitation of and counselling/psychological services

ii. any form of education including after-school activities, work attachment, enrichment, and other programmes and services for the development of the individual and/or his family;

iii. any form of financial assistance such as subsidies, grants, tax reliefs, vouchers or bursaries; and

iv. schemes administered by CPF Board (e.g., MediShield Scheme) and all other services that may be provided by the Participating Agencies.

d) “Participating Agencies[2]” refer to statutory boards and organisations which are involved in the provision of the Services and Schemes and have been approved by the Government to collect, share or use Personal Information under a valid consent form. New Participating Agencies may be included from time to time.

This consent shall be governed by and construed in accordance with the laws of the Republic of Singapore

[1] This includes any services for children or young persons including children who are beyond parental control and adoption services.
[2] Please refer to https://www.msf.gov.sg/policies/Social-Service-in-Singapore/Pages/Data-Management-and-Sharing.aspx for the list of participating agencies.

[1] This includes any services for children or young persons including children who are beyond parental control and adoption services.

[1] Please refer to https://www.msf.gov.sg/policies/Social-Service-in-Singapore/Pages/Data-Management-and-Sharing.aspx for the list of participating agencies.

By signing below, I declare that all the above information is accurate, and I understand, consent and agree to all the above as stated in points 1 - 7.
Signature of Parent/ Legal Guardian

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Signature of Youth

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Date

YearMonthDay
Indicate name and relationship of translator (if any):
e.g., Name (Relationship)
Should be Empty:

Informed Consent & Indemnity Form

Personal Particulars of Child/Ward (Youth) and Parent/ Legal Guardian

1. Medical Declaration