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.

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.

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.

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.

1. Activity Participation

Health Education Council (HEC) program participants may be eligilbe to participate in Power of Exposure activities. Power of Exposure activities may include recreational, social, educational, cultural, outdoor, and other community-based activities. Activities may include, but are not limited to, rage rooms, fishing, water parks, amusement parks, escape rooms, mini golf, sporting or recreational activities, and other field trips or outings.

I understand that participation in Power of Exposure activities is voluntary. I understand that activities may involve varying levels of physical activity, environmental conditions, equipment, interaction with other participants or members of the public, and other risks that may vary depending on the activity and location.

I understand that participation may involve risks including, but not limited to, slips, trips, falls, collisions, cuts, bruises, strains, sprains, physical exertion, exposure to weather or environmental conditions, water-related risks, use of recreational equipment, property damage or loss, and other accidental injury or unforeseen circumstances.

I understand that certain activities may involve additional or unique risks. I agree to follow reasonable safety instructions provided by Health Education Council (HEC) staff, volunteers, activity providers, venue staff, instructors, lifeguards, or other authorized personnel.

I understand that participation in an activity is voluntary and that I, or the minor participant for whom I am signing, may choose not to participate in an activity or may stop participating at any time, subject to reasonable safety and program procedures.

2. Health, Medical Conditions, Disabilities, and Accommodations

I understand that participants may have medical conditions, disabilities, allergies, or other circumstances that may affect participation in certain activities.

I agree to inform HEC staff of any relevant condition, limitation, allergy, accessibility need, or other circumstance that may affect the participant's ability to safely participate or that may require an accommodation or assistance.

I understand that HEC will make reasonable efforts to consider disclosed accommodation and accessibility needs, but that not every activity or venue may be accessible or appropriate for every participant.

I understand that I am responsible for making decisions regarding participation based on my own, or my minor participant's, abilities, limitations, and comfort level.

3. Third-Party Providers and Venues

I understand that some Power of Exposure activities may take place at facilities operated by, or be provided by, independent organizations, businesses, instructors, or other third-party providers. These may include water parks, amusement parks, recreational facilities, entertainment venues, instructors, and other activity providers.

I understand that third-party providers and venues may have their own rules, safety requirements, terms, and liability waivers. I agree that the participant will comply with applicable rules and requirements of the activity provider or venue.

I understand that the participant may be required to complete an additional waiver, release, or liability form provided by a third-party provider or venue in order to participate.

4. Assumption of Risk

I, or the minor participant for whom I am signing, voluntarily choose to participate in Power of Exposure activities and acknowledge that participation involves inherent and reasonably foreseeable risks.

I understand and voluntarily assume the ordinary risks reasonably associated with participation in these activities.

5. Release of Liability

To the fullest extent permitted by applicable law, I release and hold harmless Health Education Council (HEC), its directors, officers, employees, staff, volunteers, agents, and representatives from claims arising from the participant's participation in Power of Exposure activities, except to the extent such release is prohibited by law.

I understand that this waiver applies to Power of Exposure activities generally and is intended to supplement the Program Participation Consent and any applicable Transportation Consent and Liability Waiver.

I understand transportation to Power or Exposure trips may not be provided by HEC unless otherwise arranged by HEC staff.

6. Parent/Legal Guardian Consent for Participants Under 18

If the participant named below is under 18 years of age, I represent that I am the participant's parent or legal guardian and have the authority to provide consent on the participant's behalf.

I give permission for the minor participant named below to participate in Power of Exposure activities covered by this form. I confirm that I have reviewed the information in this form with the minor participant, as appropriate for their age and understanding, and have discussed the nature and risks of participation.

I understand that activities may vary and that some activities or venues may require additional parental/guardian consent or an additional waiver.

7. Acknowledgment and Signature

I have carefully read and understand this Activity Participation, Assumption of Risk & Liability Waiver. I understand that participation in Power of Exposure activities is voluntary and that applicable safety rules and instructions must be followed.

I understand that this form may be used for participation in multiple Power of Exposure activities during the applicable program registration period and that certain activities or venues may require additional forms.