• Red circle with orange flower petals logo and the words Health Education Council Health happens together

  • SHOP Parent/Guardian Permission Form

  • Thank you for your interest in the Health Education Council's SHOP Program. Youth ages 12-17 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

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What are the youth's pronouns?
  • Youth Applicant Birth Date*
     - -
  • How do you describe the youth applicant's race/ethnicity? (check all that apply)*
  • What type of health insurance does the youth currently have?*
  • Does the youth currently have medical insurance?*
  • If you responded yes to the previous question, which insurance company do you have?*
  • If you are on Medi-Cal, please select the Managed Care Plan*

  • 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 SHOP participants.

  • The SHOP Program is funded by the California Office of Emergency Services (CalOES) to provide support to individuals who have 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.

  • Has the youth applicant 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 your child, they may not be eligible for this program. Reach out to SHOP@healthedcouncil.org if you have questions or would like to verify you child's eligibility.

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

  • Parental Consent & Liability Waiver

  • Participation Consent
    I consent for my child 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 for my child to participate in program activities and assume responsibility for the risks resonably associated with my child's 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 child's 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 child's behalf if I am unable to do so myself. I understand that reasonble efforts will be made to contact my child's designated emergency contact as soon as possible.

     

    Code of Conduct Acknowledgement
    I agree my child will 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:*

  • Pickup Authorization

    If an individual is not on the pickup list below, they will not be allowed to pick up your child. Please include all indviduals who you may need to pick up your child.

    Note that any individuals not on this list will need prior written consent from you via text message or e-mail to pick up your child.

  • In addition to myself, I authorize the following individuals to pick up my child:
  • 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.

  •
  • Has the youth applicant ever been involved in the juvenile justice system?*
  • 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.*
  • Has the youth applicant ever been in foster care (under the legal responsibility of the child welfare agency, including foster homes and group care)?*

  • Youth Participant Pre-Survey

    Please have your child complete this page so we can learn more about them.
  • How should we refer to you?
  • I have joined this group to...*

  • How much do the following sentence describes you?

  • I have someone who I can share my feelings and ideas with.*
  • I know how to get help when dealing with conflict.*
  • I like myself.*
  • I think about my choices before making a decision.*
  • I have difficulty controlling my anger.*
  • I try new things even if they are hard.*
  • I can prepare a meal for myself.*
  • Today's Date*
     - -

  • Participant Permission Form

    I, * , as the parent or legal guardian of * , a minor, hereby give permission for my child to participate in activities related to the SHOP program organized by Health Education Council (HEC). I understand that participation in this program may include, but is not limited to, health youth groups, group discussions, interactive activities, and other events facilitated or supervised by HEC staff and volunteers.

  • 1. Consent for Transportation

    I,    *  , as the parent or legal guardian of     * , a minor, hereby give permission for my child to be transported to and from    by transportation arranged by The Health Education Council (HEC), if provided. 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.


    2. Assumption of Risk

    I acknowledge that transportation, whether by rideshare, private vehicle, or HEC staff, involves inherent risks, including but not limited to accidents, injuries, vehicle malfunctions, delays, and exposure to unforeseen hazards. I understand that while HEC aims to use reliable and insured transportation options, it cannot guarantee the safety, policies, or actions of third-party providers or drivers.

    I also understand that if my child is transported in a vehicle driven by an HEC staff member or volunteer, HEC ensures that such individuals possess a valid driver’s license and proof of insurance, but I acknowledge that HEC does not assume liability for any accidents, injuries, or incidents that may occur during transportation.

    I voluntarily assume all risks associated with my child’s transportation and agree that my child’s participation is at our own risk.

    3. Release of Liability & Indemnification

    I, on behalf of myself, my child, and our heirs, executors, administrators, and assigns, hereby release, waive, and hold harmless The Health Education Council (HEC), its officers, directors, employees, volunteers, agents, and affiliates from any and all claims, liabilities, damages, losses, or injuries arising out of or in connection with my child’s transportation, including but not limited to personal injury, death, property damage, or financial loss, whether caused by negligence or otherwise.

    I further agree to indemnify and defend HEC against any claims, damages, or expenses, including attorney’s fees, brought by or on behalf of my child related to their participation in the transportation.

    4. Staff & Volunteer Transportation Policy

    I understand that if my child is transported in a vehicle driven by an HEC staff member or volunteer, the following applies:

    • All HEC staff and volunteers must have a valid driver’s license and proof of insurance.
    • HEC does not assume responsibility for staff or volunteer vehicles, including insurance coverage, accidents, or mechanical failures.
    • HEC staff and volunteers are expected to follow all traffic laws and safety protocols but are not liable for unforeseen incidents.
    • At no time will a single staff member transport a minor alone unless prior written consent is provided by the parent/guardian.


    5. Medical Emergency Authorization

    In the event of an emergency during transportation, I authorize HEC staff, volunteers, or transportation providers to seek emergency medical treatment for my child if I cannot be reached. I acknowledge that I am responsible for any medical costs incurred.

    6. Compliance with Transportation Policies

    I understand that:

    • Uber, Lyft, and other rideshare companies prohibit unaccompanied minors from riding unless part of an authorized youth program.
    • If my child is found to be ineligible for a transportation method, alternate arrangements may be required, which could delay transportation or require me to pick up my child.
    • HEC reserves the right to deny transportation to any youth based on safety concerns.


    7. Acknowledgment and Agreement

    I have carefully read this Parental Consent & Liability Waiver and fully understand its terms. I acknowledge that I am signing this waiver voluntarily and with full knowledge of its significance.

  • 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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