Release of Liability:
On behalf of myself and my household members, I hereby release and hold harmless The Ada Jenkins Center and its employees, agents, and partnering agencies from any and all liabilities, costs, or consequences related to the services provided, including but not limited to injury, death, damage, or loss of property. I understand that this agreement applies to any act or failure to act by The Ada Jenkins Center, its employees, or agents. I agree not to hold The Ada Jenkins Center or its employees or agents responsible for damages, and I will not pursue any legal action against them.
Purpose of Services:
I understand that the information provided by The Ada Jenkins Center and its partnering agencies is for educational purposes only and is not a substitute for expert consultation or advice. The services are intended to educate and inform families about resources such as financial literacy, employment skill-building, educational opportunities, life skills, and budgeting to strengthen families and promote stability.
I hereby agree to hold harmless and waive any rights or causes of action against The Ada Jenkins Center and partnering agencies for any financial or other damages resulting from the services provided.
Term of Agreement:
This agreement will remain in effect from the date of signing until my departure or the termination of the services provided.
Confidentiality and Data Consent:
I understand that my information will be kept confidential, and no information will be shared unless it is essential to assisting me. The Ada Jenkins Center will request my permission before releasing any information to partner organizations or other providers. Additionally, I authorize the entry of my information into The Ada Jenkins Center’s computer database. This consent is valid for one year and may be revoked at any time by submitting a written request.
Limits on Confidentiality:
- I acknowledge that certain situations require disclosure of confidential information by law. These include:
- If I am deemed a danger to myself or others.
- If a child under the age of 18 reports or is suspected of being a victim of abuse (physical, emotional, or sexual) or neglect.
Authorization for Release of Information
I authorize The Ada Jenkins Center and other individuals, agencies, or organizations listed within this application to release and receive information relative to obtaining services on my behalf and for my dependents under 18. This information may include service plans, benefits eligibility, and health-related data. The consent remains valid from the date of consent, not exceeding one year.
Agreement and Acknowledgment:
By signing below, I confirm that I have read and understood the above information, and I have had the opportunity to ask any questions. I agree to the terms and conditions as outlined in this Consent and Agreement.