Consent and Waiver - I understand that the program requires an 8 week commitment and that all program costs are covered by Los Alamos JJAB. I understand that I may contact the JJAB One Circle facilitator or JJAB One Circle coordinator with questions or comments about the One Circle: Girls group or One Circle: Boys group. I understand that One Circle groups encourage creative and verbal expression and that the group guidelines provide the foundation for circle communication.
For the purpose of effective program facilitation, I authorize the mutual exchange of information regarding my child’s participation in One Circle between the JJAB One Circle Facilitator, JJAB One Circle Coordinator, myself as the parent/guardian of the undersigned child, and if applicable the site school’s counselor or Teen Court coordinator.
All information will remain confidential per the JJAB Privacy Practices, unless I have authorized its exchange, except in the following circumstances: danger of one acting on suicidal or homicidal thoughts, danger of injury to oneself or others, suspected child or vulnerable adult abuse or neglect, or court subpoena. I have received the Notice of JJAB Privacy Practices. This authorization may be revoked at any time by submitting a written request to the JJAB Executive Director (P.O. Box 4716, White Rock, NM 87547). I hereby certify that this request has been made voluntarily.
I release Los Alamos JJAB, its contractors, and its employees, from liability for any claims by me or any third party in connection with the participation of the undersigned minor child. I hereby give my consent for the undersigned child below to participate in the above program.