tyc docs

Consent for Release
For participants 18+
Program Participant Name:*
First NameLast 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 Signature (18 & Up Only)*
Clear
Date*
MonthDayYear
Date
Participant Name*
First NameLast Name
Emergency Contact Name:*
First NameLast Name
Emergency Contact Number:*
Insurance Carrier:*
Policy/Plan#:
Regular Medications:*
Special Health Conditions:*

Informed Consent Release Waiver, Assumption of Risk and Identification
Agreement Adult Participant in The Youth Connection Career Academies
In consideration of my participation in The Youth Connection Career Academies (TYC) and any and all events or activities in relation thereto (collectively the “Activity”) permitted by The Youth Connection, Inc. and with the understanding that my participation in the Activity is only on the condition that I enter into this agreement for myself, my heirs and assigns, I hereby assume the inherent and extraordinary risks involved in the Activity, and any risks inherent in any other activities connected with the Activity in which I may participate.
I expressly assume the risk of and accept full responsibility for any and all injuries, including death, which may occur as a result of my participation in the Activity and release from liability The Youth Connection, State of Michigan, other partner agencies, its and their officers, directors, agents, representatives, heirs and employees. I hereby waive any and all claims I may hereafter have as a result of any and all injuries disease or sickness, including death, due to my participation in the Activity. I hereby agree to indemnify all of the above named persons for any and all claims, including attorney’s fees and costs, which may be brought against any of them by anyone claiming to have been damaged as a result of any injury, sickness or disease, including death, to my person or property which may occur as a result of or during the Activity. I understand that the Activity may be dangerous and that physical injury, property damage or death may result. I certify that I have read and fully understand this release. I am of lawful age and legally competent to make this agreement. I understand that I am waiving any and all claims I may have against TYC, its officers, directors, agents, representatives, heirs and employees as the result of my participation in the Activity.
I agree and understand that it is my responsibility as the participant to: 1) fully disclose any health issues or medications that are relevant to my participation in any TYCCA Programs; 2) inform the instructor if there are activities with which I do not feel comfortable; 3) cease exercise and report promptly any unusual feelings (e.g., chest discomfort, nausea, difficulty breathing, apparent injury, etc.) during the program; and to 4) medically clear my participation by completing a health screening appraisal form prior to beginning this program.
It is understood and agreed that the release of liability, waiver and covenant not to sue, indemnification and hold harmless and assumption of risk provisions of this Agreement shall also apply to any claims or liability that may result from any emergency first aid, medical treatment or transportation provided to me, the adult participant, under the terms of TYCCA Programs Emergency Medical Treatment Authorization Form executed by me, the adult participant.
Severability: The undersigned further expressly agrees that the foregoing release of liability, waiver and covenant not to sue, indemnification and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the laws of the State of Michigan. If any portion of the Agreement is found to be invalid by a court with jurisdiction over the matter, it is agreed and understood that the balance of the Agreement shall remain in full legal force and effect.
Acknowledgment of Understanding: I have read this release of liability, waiver and covenant not to sue, indemnification and assumption of risk agreement and fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I agree this form has been fully explained and I have been given an opportunity to ask questions and to seek legal advice. I believe that I have sufficient information to give this informed consent. I further understand and accept that additional risks and hazards may be involved. Finally, I acknowledge that I am 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.
THIS IS A RELEASE. READ CAREFULLY BEFORE SIGNING.
Print Name Participant:*
First NameLast Name
Signature of Participant:*
Clear
Date:*
MonthDayYear
Date
Address
Address of Participant
Street Address Line 2
CityState
Zip
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Consent for Release

Informed Consent Release Waiver, Assumption of Risk and Identification