1. OMNI Youth services/IL Human Performance Project to provide my child prevention programming and services. I understand that such permission may be revoked, in writing, at any time. As an OMNI Youth Services/IL Human Performance Project service recipient, I have the right to refuse program services.
2. OMNI Youth Services/IL Human Performance Project to publish or release photographs or videotape of participant named above. Providing consent to OMNI Youth Services and the IL Human Performance Project for releasing photographs and/or videotape is voluntary and will not impact the services I am currently involved in, or may be involved with in the future. I/We understand that the photographs/videotape may be used for one or more of the following purposes: brochures/ publications, advertisements, flyers, grant reports, OMNI Youth Services and/or IL Human Performance Project web page and/or social networking sites, office reception areas, and promotional videotapes. If you are opposed to one or more of these uses for photo or videotape, check the box indicating so below and sign. This consent is subject to written revocations at any time except to the extent that release or publication has already occured. This consent must be revoked in writing to be considered invalid. I understand that these are photographs or videos that may be taken while I engage in OMNI Youth Services and/or IL Human Performance Project facilitated events. It is understood that a refusal to authorize the release of photographs/videotape will prevent disclosure to the person/organization identified above.