Youth Event Permission Waiver

Youth Event Permission and Waiver
YPR is a national nonprofit that provides peer recovery support services for youth and young adults in recovery—or who are seeking recovery—from substance use disorder. Our programs consist of community-based chapters; life-skills curriculum programs; and advocacy to reduce stigma and create more resources for recovery. By creating a national network of young people in recovery, YPR empowers young people to get involved in their communities and take charge of their futures.

YPR embraces all pathways to recovery including 12-step, faith-based, harm reduction, medication-assisted treatment, and others. YPR was formed in 2010 by young people in recovery (defined as under age 30) who wanted to help others. It was incorporated as a 501c3 effective 2013. YPR currently has 54 chapters in 19 states nationwide with new chapters launching throughout the year. Our first life-skill curriculum program, My Recovery Is EPIC, was launched in 2016. YPR now has three life-skills curriculum programs, including the Phoenix program for criminal justice-involved individuals and My Future Is EPIC for adolescents aged 14-18.

The organization is led by Executive Director Ann Herbst, YPR’s former VP of Institutional Advancement. Please complete this Youth Permission and Waiver for eachyouth prior to his/her participation in the YPR program(s) listed below (“Program”).
PROGRAM/EVENT INFORMATION

(To be completed by YPR)
Program/Event Name
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Destination
Name of YPR Staff Member who will accompany the minor:

First NameLast Name
Brief Description of Activities:

The YPR event is a unique opportunity to explore groundbreaking organizations, innovative products, and inspiring individuals dedicated to transforming the lives of young people in recovery. This event is your chance to connect with advocates, leaders, and allies who are actively shaping the future of the recovery movement!

Discover New Perspectives: Engage with thought leaders sharing best practices and success stories in youth recovery.

Networking Opportunities: Connect with peers, experts, and inspirational figures in the recovery community.

Be Inspired: Witness firsthand the positive impact of recovery support services and advocacy efforts.
Youth Information

(To be completed by Parent/Guardian of Youth)
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email (If youth age 13 and up, otherwise use parent/custodial e-mail address)
example@example.com
Date of Birth

MonthDayYear
Date
FemaleMaleNon-BinaryPefer not to say
Previous Participation. Has your youth participated in a YPR program before? If yes, which and when?
Health History. Please describe any medical conditions, including all allergies and current medication, that may affect your youth’s ability to participate in the Program. Please list medication and dosage of any medication your youth may need to take during his/her participation in YPR programs. Please indicate if your youth carries an EPI-PEN or asthma inhaler.
Peanut AllergiesTreenut AllergiesDairy restrictions/allergiesSeafood/ShellfishGluten AllergriesOther
Physician Name
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Health Insurance Provider
Group Number
Member Number
FIRST PARENT/LEGAL GUARDIAN INFORMATION

(required)
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
YesNo
SECOND PARENT/LEGAL GUARDIAN CONTACT INFORMATION

(if applicable)
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
YesNo
EMERGENCY CONTACT

(If different than Parent/Legal Guardian)
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to youth
PERMISSION TO PHOTOGRAPH AND/OR VIDEOTAPE

Photographs and/or videotapes may be made during regular and special YPR activities. These images may be used in program presentations at conferences, as part of YPR's social media accounts to promote Young People in Recovery's mission and promotion of our services. We may also use special photographs or videotapes in specific projects such as program brochures or community calendars and social media. Throughout the year, we will publicize events and photos on our website, Facebook, Instagram, TikTok.

I hereby grant permission for my child to have his/her photograph and/or video image taken by the staff of Young People in Recovery. I understand that some of these photographs may be used in newsletters, social media, and other publications including the YPR website. We will not identify any student individually. Some information may be available on the internet but will not identify any student individually. I understand that this permission form is valid for one year from the date signed.
Signature
Date

MonthDayYear
Date
PERMISSION AND WAIVER

By signing below, I, the youth’s parent or legal guardian, agree that:

Permission. I grant express permission for my youth to participate in the Program. I understand that my youth may be excluded from participation if he or
she does not comply with YPR’s safety rules and directions.

Permission for Transportation. I authorize YPR staff and/or volunteers to transport my youth in vehicles to Program sites if required for his/her participation in the Program or event.

Awareness and Assumption of Risk. I understand that my youth’s activities in the Program or event have inherent risks that may arise directly or indirectly from the activities themselves, my youth’s own actions or inactions, the actions or inactions of YPR, its directors, officers, employees and agents, volunteers, participants, constituents, and others present at the program, transportation to and from Program or event sites by YPR staff and/or volunteers and dangers and conditions at Program sites. I assume full responsibility for any and all risks of bodily injury, death or property damage caused by or arising directly or indirectly from my youth’s presence at Program sites or participation in the Program, regardless of the cause.

Waiver and Release of Claims. In consideration for my youth’s participation in the Programs or events, I waive and release any and all claims against YPR, its directors, officers, agents, members, employees, volunteers, participants, constitutes, and affiliates (collectively, the “YPR Parties”), for any liability, loss, damages, claims, expenses and attorneys’ fees resulting from death or injury to my youth or property, caused by or arising directly or indirectly from my youth’s presence at Program sites or participation in the Program, regardless of the cause and even if caused by negligence, whether passive or active. I agree not to sue any of the YPR Parties on the basis of these waived and released claims. I waive the protections of Section 1542 of the California Civil Code, which provides that a general release does not extend to certain claims not known to me at the time I signed this waiver and release, any similar laws in any other state(s).

Medical Care Consent and Waiver. I authorize YPR to provide to my youth first aid and, through medical personnel of its choice, medical assistance, transportation, and emergency medical services. This consent does not impose a duty upon YPR to provide such assistance, transportation, or services. In addition, I waive and release any claims against the YPR Parties arising out of any first aid, treatment or medical service, including the lack or timing of such, made in connection with my youth’s activities in the Program.

Indemnification. I will defend, indemnify, and hold the YPR Parties harmless from and against any and all liabilities, losses, damages, claims and attorney’s fees that may be suffered by any YPR Party resulting directly or indirectly from my youth’s presence at Program sites or participation in the Program, except and only to the extent the liability is caused by the gross negligence or willful misconduct of the relevant YPR Party.

Publicity. I consent to the use by YPR of my youth’s image, voice, name and/or story in any format, including video, print or electronic (collectively, the “Materials”), as YPR may deem appropriate to promote its programs. YPR may make the Materials available at its discretion to third parties, on YPR’s website, in YPR’s publications, or through any other media, including social networking websites. I waive any right to inspect or approve the finished product or to receive any payment. I grant to YPR all copyrights in the Materials and waive any legal claims, including those relating to copyright, or rights of publicity or privacy.

I, the parent/guardian of the student named above, agree with the following statements:
- I hereby give permission for my child to take part in the Program or event described above.
- I understand that I am responsible for getting my child to and from the departure and return sites identified above. I understand that my child shall be accompanied by staff member(s) during the trip, including while traveling from the departure site to the destination site, and from the destination site to the return site.
- I understand that my child is expected to behave responsibly and to follow YPR's discipline code and policies.
- I agree that in the event of an emergency injury or illness, the staff member(s) in charge of the Program or event may act on my behalf and at my expense in obtaining medical treatment for my child.
Signature
Date

MonthDayYear
Date
Should be Empty:

Youth Event Permission and Waiver

PROGRAM/EVENT INFORMATION

Youth Information

FIRST PARENT/LEGAL GUARDIAN INFORMATION

SECOND PARENT/LEGAL GUARDIAN CONTACT INFORMATION

EMERGENCY CONTACT