Consent for Release Adult

Consent & Release Form Adult
For participants 18+
Program Participant Name:*
Age:*
Media Release: I hereby authorize The Youth Connection, Inc. and its partners, funders and/or media to interview and/or take photographs, audio, videotapes or digital recordings of the participant named above and I agree that The Youth Connection may use or permit other persons to use the negatives, prints, information or media, now or hereafter known, and exclusively for the purpose of The Youth Connection. (Please type your initials below) *
I consent that my name may be disclosed. I release all rights to The Youth Connection, and its partners to exhibit this work in print and electronically, publicly or privately, and to promote and/or distribute copies for Public News Media, Education, Grants/Annual Reports, Website, Promotional and Educational Videos, Advertising, etc. I waive any proprietary rights to this material and forego any right, entitlement, or claim I might otherwise have and any financial compensation in accordance with the above. I hereby consent and agree to release The Youth Connection and its partners from any liability arising out of the distribution of the interview, photo or audio visual recording. (Please type your initials below)*
Consent for Release of Information: By signing below, I hereby authorize my past, present and future employers, child welfare agencies, and educational institutions to share relevant information with The Youth Connection, Inc. pertaining to the education, employment, training and/or wage information, for the above named participant, concerning the education, employment, training and/or wages, qualifications, and work readiness training, with the State of Michigan, City of Detroit, and all other program partners and appropriate agencies for the purposes of providing effective career development and case management services for year-round and/or summer programming. (Please type your initials below)*
Travel & Field Trip Consent: I hereby give permission for the participant named above to leave the designated training site, with supervision from The Youth Connection staff, its training instructors and its worksite supervisors for travel by walking, car, van, or bus to attend various field trips. I understand that every precaution and care will be taken to ensure my safety. Adults will provide proper supervision and must hold a valid driver's license and auto coverage in accordance with the State of Michigan regulations. (Please type your initials below)*
Consent for Emergency Medical Treatment: I hereby authorize The Youth Connection, Inc. and its partners to obtain my, medical information in the event of an emergency. I hereby give consent for emergency medical treatment and to be transported by car, ambulance, or air to an emergency center for treatment for the above named participant. I agree and acknowledge that necessary treatment can be administered as prescribed by a first aid trained and/or qualified medical personnel. I agree to indemnify, defend and hold The Youth Connection, Inc. and its representatives harmless from and against any and all liability that may result from any of these actions. (Please type your initials below)*
Acknowledgement of Responsibility: I hereby acknowledge and agree to take sole responsibility for all my actions upon leaving The Youth Connection, Inc. offices, training worksite, and/or the assigned Summer Worksite partner locations during scheduled breaks and/or lunch periods. I understand that I am expected to return to within the permitted timeframe provided. I understand that failure to return on time may result in being dismissed for the remainder of the day without pay or compensation. I agree to indemnify, defend and hold The Youth Connection, Inc. and its partners harmless from and against any and all liability that may result from an accident or emergency due to me leaving the program premises and/or facility during scheduled work hours, including breaks and lunch. (Please type your initials below)*
Authorization & Consent for Participation: By signing below, I agree that I read all sections of this form, front and back and fully understand all of the consents outlined in this document to which I agree to adhere accordingly. I acknowledge that I'm signing this agreement freely and voluntarily, and intend for my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. My signature also confirms that I undertand the conditions of my participation in The Youth Connection Career Academies and the services available to me.

I further understand that The Youth Connection (TYC) operates multiple programs and receives various sources of funding. Therefore, program information and guidelines that apply to me may not neccessarily apply to other participants and I should govern myself according to the information provided to me by TYC staff only. I understand that any information I provide to TYC is confidential and will only be shared with neccessary parties to provide supportive services, case management, educational support, and/or medical treatment for me, as needed.
Participant Name *
Participant Signature (18 & Up Only)*
Clear
Date*
MonthDayYear
Date
Emergency Information
Emergency Contact Name:*
Emergency Contact Phone Number*
Please enter a valid phone number.
Insurance Carrier:*
Policy/Plan#:
Regular Medications:*
Special Health Conditions:*
Should be Empty:

Consent & Release Form Adult

Emergency Information