Please describe your child's academic strengths and challenges:

This gives my permission for the above-mentioned child to be involved in Youth Guidance of Indian River County.

Permission is also given to Youth Guidance to transport my child to and from school, recreational activities, etc.

I release Youth Guidance and its volunteers for any liability of lost, stolen, and/ or damaged items that may occur while my child participates in any Youth Guidance activity or personal activity with volunteer(s), employees, or board members. If my child needs any emergency medical treatment while in the volunteer's care, this is my authorization for such treatment (if I cannot be reached). This is also my authorization to the attending physician and emergency care facility. I assume the expense of any medical care.

I give permission for Youth Guidance and its volunteers, employees, or board members to seek medical treatment for my child if they are unable to reach any parent or guardian. I also agree that I will be responsible for any financial debt that is accumulated by said action.

This is also the authorization of the child and parent/guardian for you to provide Youth Guidance full particulars regarding the child's mental and/or psychological and psychiatric history and any other pertinent information requested.

Further, this authorizes all agencies involved with the child to release all information to Youth Guidance.

...by Youth Guidance, United Way, Indian River County and other groups involved with Youth Guidance for advertising, sponsorship, educational and/or publicity purposes in all publications, Web sites, television, social media, advertisements and publicity materials, without limitations or reservation, as deemed appropriate by the organization. I also consent to any testimony or text written about the person named above that may accompany said photographs or stand-alone in all publications, advertisements and publicity materials, without limitation or reservation, as deemed appropriate by the organization. I understand that I will receive no remuneration due to my child's photo.

I agree that I will not assert or maintain against Youth Guidance, United Way, Indian River County and other groups involved with Youth Guidance, their successors, assigns and licensees, any claim, action, suit or demand of any kind or nature whatsoever, including but not limited to, those grounded upon invasion of privacy, rights of publicity or other civil rights, or for any other reason in connection with the authorized use of my physical likeness and sound in the picture as herein provided. I hereby release Youth Guidance, United Way, Indian River County and other groups involved with Youth Guidance, their successors, assigns and licensees, and each of them, from and against any and all claims, liabilities, demands, actions, causes of action(s), costs and expenses whatsoever, at law or in equity, known or unknown, anticipated or unanticipated, which I ever had, now have, or may, shall or hereafter have by reason, matter, cause or thing arising out of the use of any images as herein provided.

For Youth Guidance to provide high quality programs and build positive group/one-on-one mentoring relationships, our students and families must also dedicate their time and effort towards our program. The best way to accomplish these goals is to ensure that we have maximum participation and daily attendance from our families. Attendance is one of the tools we use to measure your child's improvements.

Students will be allowed three (3) excused absences before being taken out of ALL programs for the remainder of the current semester. The number of tallied excused absences will start over at the beginning of each new semester (summer camp is considered 1 semester).

Contact must be made between Youth Guidance Staff and the parent/guardian prior to or on the day of the absence, or confirmation of absence must be secured upon the student's return to Youth Guidance.

Lack of following this attendance policy will result in your child being removed from the current program and placed on the waitlist or given last priority upon enrolling in future semesters.

The following constitutes excused absences:

1. Medical/Illness or Injury
2. Death in the family
3. Religious observances
4. Family Vacation
5. School Function

☑ Disclose education records described below

☑ Receive/Obtain education records described below

 

TO/FROM (Authorized Party)

 By way of:

☑Electronic

☑Verbal

☑Written

The specific information being released:

☑ Grades
☑ Discipline Records
☑ Attendance Records
☑ Teacher/Staff Contact Info
☑ Academic data (FAST data, iReady data, progress reports, grades, and other assessments)
☑ 504 Plan (if applicable)
☑ Individualized Education Plan (if applicable)
☑ Behavior Intervention Plan (BIP) (if applicable)

For the purpose of:

☑ Continuity of Educational Support

NOTICE OF RIGHTS UNDER FERPA

The education records of students are protected under the Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. § 1232g and 34 CFR Part 99, and applicable Florida law, including Florida Statutes § 1002.22. These records may not be disclosed without the written consent of the eligible student or parent/guardian, except as permitted by law.

Prohibition on Re-Disclosure: The party receiving these education records may not re-disclose them to any other party without a new written authorization from the parent/guardian or eligible student, except as permitted by FERPA. Records shared under this authorization are to be used solely for the purpose(s) stated above and must be maintained in a confidential manner.

Your Rights: As a parent/guardian (or eligible student aged 18+), you have the right to: (1) inspect and review the student's education records; (2) request amendment of records believed to be inaccurate or misleading; (3) consent to disclosures of personally identifiable information, except as authorized by FERPA; and (4) file a complaint with the U.S. Department of Education concerning alleged failures to comply with FERPA (Family Policy Compliance Office, U.S. Dept. of Education, 400 Maryland Ave SW, Washington, DC 20202).

Revocation: You may revoke this consent at any time by providing written notice to Youth Guidance of Indian River County, Inc., except to the extent that action has already been taken in reliance on it.

AUTHORIZATION

By signing below, I confirm that I have read and understand the contents of this Release of Information, including the purpose for which information is being released, the parties involved, and my rights regarding this consent.

Youth Guidance provides Academic Enrichment, Career Development/Life Skills and Vocational Training for the families who reside in OR attend school in Indian River County. Through group mentoring programs, the goal is to prepare students for success in and after high school.

For your child(ren) to participate and maintain their scholarship in the Youth Guidance Program, the following criteria requirements must be met by the student.

The STUDENT will/does: (refer to Parent Handbook)

• Qualify for free or reduced lunch.
• Reside in or attend public, charter, private or homeschool in Indian River County.
• Attend and participate in all group activities enrolled in weekly.
• Adhere to the program expectations set by the Youth Guidance Staff on and off-site.
• Submit a copy of their report card QUARTERLY to Youth Guidance Staff.
• Adhere to the 3-Strike Policy and maintain reasonable behavior by being honest and respectful to staff members, volunteers, mentors, peers, and community partners while participating in Youth Guidance Programs.  Behaviors to avoid include:
  • Fighting
  • Disrespecting Staff
  • Inappropriate language (ex: profanity and obscene gestures)
  • Stealing
  • Vandalism/destruction of property
  • Inappropriate touching
  • Bullying
  • Illegal activity (ex: drug or alcohol use, possession of weapons)
• Dress in a manner that allows full participation in our programs.
• Clothing that is prohibited includes:
  • Clothing/jewelry that displays logos or images that promote drug use, alcohol, violence, or racism.
  • Open-toed shoes (ex: crocs, sandals, or slides).
  • Clothing that exposes the midriff or other parts of the body (ex: crop tops, spaghetti straps, booty shorts, see-through apparel, skintight clothing, etc.)
• Adhere to the Youth Guidance cellphone/electronics policy.
  • Students can use their cell phones during the time frame given by Youth Guidance program staff. Additionally, staff may permit phone use at other times for Educational or Emergency purposes.

For your child(ren) to participate and maintain their scholarship in the Youth Guidance Program, the following criteria requirements must be met by the parent.

The PARENT will:

1. Sign-up your child for Youth Guidance programs during the registration period. Registration is on a first come, first served basis. If there is no room available for your child, they will be placed on a wait list and will be contacted if space is made available.

2. Adhere to the Youth Guidance Attendance Policy and notify staff if your child will be early, late, or absent.

3. Ensure that your child meets the standards of behavior in all Youth Guidance related programs.

4. Provide QUARTERLY report cards if attending private or being home-schooled.

5. Will participate in QUARTERLY meetings if your child is failing (D or F) in subjects at school.

6. Make sure your child arrives and is picked up on time for programs. *Late fees will be applied

7. Walk in with your child and sign them in and out.

8. Inform staff of any special needs your child may have, when there is a change in your contact info and if your child changes schools.

9. Not go past the front lobby without the permission or escort of a Youth Guidance staff member.