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  • SHOP Young Adult Registration Form

  • Thank you for your interest in Health Education Council's SHOP program. Young adults ages 18-25 in Sacramento, Placer, and Yolo County who have experienced violence, witnessed violence, or have a close family member who has experienced violence, are eligible to register.

    This form is confidential and will only be shared with SHOP staff, unless disclosure is required by law or authorized by you.

     

    For any questions please email SHOP@healthedcouncil.org.

  • How should we refer to you?
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Gender*
  • How do you describe your race/ethnicity? (check all that apply)*
  • What county do you live in?*
  • What type of health insurance coverage do you currently have?*
  • Format: (000) 000-0000.

  • Life Experience

    In order to provide the best support possible, it is helpful for us to understand the experiences you've have had. This information is only shared with SHOP staff working directly with SHOP participants.

  • The SHOP Program is funded by the California Office of Emergency Services (CalOES) to provide additional support to individuals who have witnessed, experienced, or been impacted by violence or harmful experiences.

    This includes mass violence, hate crimes, driving under the influence, kidnapping, bullying (verbal, cyber, or physical), sexual assault, child abuse, homicide, human trafficking, robbery, stalking/ harassment, domestic or family violence, and other forms of violence.

    Individuals who have been impacted by one or more of these life events may be eligible for Emergency Financial Assistance or Victim’s Crime Compensation.

  • Have you been affected by one or more forms of violence or harm listed above?*

  • Due to funding limitations, the SHOP program can only support individuals who have experienced, witnessed, or have a close family member who has experienced a life event such as the above examples.

    If this does not apply to you, you may not be eligible for this program. Reach out to SHOP@healthedcouncil.org if you have questions or would like to verify your eligibility.

  • Have you experienced situations that may have impacted your safety, well-being, or sense of security?*
  • Are there any areas where additional support or resources would be helpful for you at this time? (Examples: food, housing, transportation, mental health support, school support, etc.)*

  • Consent and Liability Waiver

  • Participation Consent
    I consent to participate in the SHOP program organized by Health Education Council. I understand that participation in this program may include group discussions, workshops, interactive activities, social events, community outings, field trips, recreational activities, and other program-related activities facilitated or supervised by Health Education Council staff or volunteers.

     

    Assumption of Risk
    I understand that participation in program activities may involve certiain inherent risks, including but not limited to accidental injury, illness, property loss, or other unforeseen events. I voluntarily choose to participate in program activities and assume responsibility for the risks resonably associated with participation.

     

    Release of Liability
    To the fullest extent permitted by law, I release and hold harmless Health Education Council, its directors, employees, volunteers, and agents from claims arising out of ordinary negligence related to my participation in program activities except where prohibited by law.

     

    Emergency Medical Authorization
    In the event of a medical emergency, I authorize Health Education Council staff or volunteers to seek emergency medical treatment on my behalf if I am unable to do so myself. I understand that reasonble efforts will be made to contact my designated emergency contact as soon as possible.

     

    Code of Conduct Acknowledgement
    I agree to treat other participants, staff, volunteers, and community members with respect and follow program rules and expectations.

     

     

    Photo and Media Consent
    Health Education Council may take photographs, videos, or audio recordings during program activities for use in promotional, educational, and outreach materials, incuding social media, websites, reports, and other publications.

  • Please select one:*
  • Today's Date*
     - -

  • Transportation Consent & Liability Waiver

  • If the participant is under 18 years of age, this form must be completed and signed by a parent or legal guardian.

  • 1. Consent for Transportation

    I authorize the Health Education Council (HEC) to arrange or provide transportation for the participant in connection with HEC programs, services, and activities.

    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

    Transportation methods may vary depending on availability, participant needs, program requirements, and safety considerations.

     

    2. Assumption of Risk

    I understand that travel by motor vehicle, rideshare, public transportation, or other transportation methods involves inherent risks, including but not limited to:

    - Motor vehicle accidents
    - Personal injury
    - Property damage
    - Mechanical failure
    - Traffic delays
    - Weather-related hazards
    - Actions of other drivers or passengers
    - Other unforeseen circumstances

    I understand that HEC will exercise reasonable care when arranging or providing transportation but cannot eliminate all risks associated with travel.

    I voluntarily assume the ordinary risks associated with transportation provided or arranged through HEC.

     

    3. Third-Party Transportation

    I understand that transportation arranged through third-party providers (such as Uber, Lyft, taxis, or public transportation agencies) is subject to the policies, insurance, operating procedures, and actions of those independent providers.

    HEC does not own, operate, or control third-party transportation providers and cannot guarantee their performance or safety.

    If a participant is not eligible to use a particular transportation service under that provider's policies, HEC may arrange an alternative transportation method or require alternate transportation arrangements.

     

    4. Transportation by HEC Staff or Volunteers

    When transportation is provided by an HEC employee or authorized volunteer:

    - Drivers are expected to possess a valid driver's license and maintain any insurance required by law.
    - Drivers are expected to follow all applicable traffic laws and HEC transportation policies.
    - Vehicles used for transportation are expected to be maintained in reasonably safe operating condition.
    - Except when specifically authorized in writing by the parent or legal guardian, a minor participant will not be transported one-on-one by a single staff member or volunteer.

     

    5. Participant Responsibilities

    The participant agrees to:

    - Wear a seat belt whenever available and required by law.
    - Follow reasonable instructions provided by the driver.
    - Behave in a manner that does not distract the driver or create unsafe conditions.
    - Treat drivers, passengers, and vehicles with respect.
    - Follow the policies of any transportation provider being used.

    HEC reserves the right to refuse or discontinue transportation if participant behavior creates a safety concern.

     

    6. Medical Emergency Authorization

    In the event of a medical emergency during transportation, I authorize HEC staff, volunteers, or authorized transportation providers to contact emergency medical services and seek emergency medical treatment for the participant if reasonably necessary.

    I understand that I am responsible for any medical expenses that may result from emergency treatment.

     

    7. Release of Liability

    To the fullest extent permitted by California law, I voluntarily release and hold harmless the Health Education Council (HEC), its officers, directors, employees, volunteers, agents, and representatives from claims arising out of injuries, losses, or damages resulting from transportation provided or arranged through HEC, except to the extent such claims result from gross negligence, reckless conduct, or willful misconduct.

    I understand that this release applies only to the extent permitted by applicable law.

     

    8. Transportation Policies

    I understand and acknowledge that:

    - Transportation is provided at HEC's discretion and may not always be available.
    - Transportation arrangements may change due to scheduling, safety concerns, vehicle availability, weather, or other unforeseen circumstances.
    - HEC may refuse transportation when necessary to protect the health or safety of participants, staff, volunteers, or drivers.

     

    9. Acknowledgment

    I certify that I have carefully read this Transportation Consent & Liability Waiver and understand its contents.

    I understand that by signing below, I am voluntarily agreeing to these terms.

    I certify that the information provided is accurate to the best of my knowledge.

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