SHOP Parent/Guardian Permission Form

SHOP Parent/Guardian Permission Form

Thank you for your interest in the Health Education Council's SHOP Program. Youth and young adults ages 16-21 in the Sacramento, Placer, and Yolo Counties who have been directly affected by untreated mental illness, violence, poverty, homelessness, incarceration, or school failure are eligible to apply. If the youth is under 18 years old, this form must be completed by a parent/guardian.
Today's Date*

MonthDayYear
Date
Parent/Guardian Name

First NameLast Name
Relationship to Youth Applicant
Parent/Guardian Phone Number
Please enter a valid phone number.
Parent/Guardian Email
example@example.com
Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact (if different than above)

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Youth Applicant Name

First NameLast Name
Youth Applicant Birth Date

MonthDayYear
Date
Youth Applicant Gender
Youth Applicant Address (if different than parent/guardian)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How do you describe the youth applicant's race/ethnicity? (check all that apply)

African American or BlackAsian or Asian AmericanCaucasian, White, European AmericanHispanic or Latino/LatinaMiddle EasternNative American, American Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderBiracial or MultiracialOther
Please list any youth applicant food allergies.
Life Experience

In order to provide the best support possible, it is helpful for us to understand the experiences youth have had. We understand that this information is highly personal. The information is only shared with SHOP staff working directly with a youth and is stored in a secured data system.
Has the youth applicant ever been in foster care (under the legal responsibility of the child welfare agency, including foster homes and group care?*

Yes, currently in foster careYes, in foster care beforeNo, never been in foster carePrefer not to answer
How would you rate the youth applicant's overall health (1 poor, unhealthy , 5 great no major health concerns)*

1 star = poor 5 stars = great
Has the youth applicant ever been involved in the juvenile justice system?

YesNoPrefer not to answer
Has the youth applicant witnessed or experienced any of the following events? If the youth experienced any of these events, they may be eligible for victims' crime compensation. Select all that apply.

HomelessnessMass ViolenceHate CrimeDriving under the InfluenceKidnappingBullying (verbal, cyber or physical)Sexual Assault as a ChildSexual Assault as an AdultChild AbuseHomicideHuman TraffickingRobberyPrefer not to answer
Can we contact you after the class to learn more about the youth's experience?*

YesNo
Permission Form for Photo/ Video/ Filming
I authorize and give permission that the Health Education Council photograph and video tape or film my child, and I as well, as long as my children participate in the program. I recognize that neither I, nor my children will be compensated by the center or by a third person for the use of the images. I give permission to the Health Education Council to use the images to demonstrate program impact on several social media, including, but not limited to Health Education Council’s website, Facebook, and Instagram pages, the newsletters, and the websites of the Office of Minority Health, Community-Oriented Policing Services, and the Center for Court Innovation.
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Permission for Home Delivery/Visits
I consent for a Health Education Council staff member to conduct a home delivery or home visit for the purpose of offering direct mentorship, case management, emotional support, resource navigation, and other follow-up services at my residence.
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SHOP Parent/Guardian Permission Form

Life Experience