* Participant Information:
Date Format: MM slash DD slash YYYY
Please list any important health information you would like our staff to be aware of, including:
Please enter any known allergies. If none, please list N/A
Please list any daily medications. If none, please list N/A
Please provide any other conditions or concerns you would like our staff to be aware of.
Date Format: MM slash DD slash YYYY
Emergency Contact (other than parent referenced above)
MUST PROVIDE AT LEAST ONE
Pittsburgh Public School Academic Release Statement
- As an approved partner with Pittsburgh Public Schools for the 2020-2021 school year, YOUTHPLACES is authorized to receive personally identifiable student educational data, including grades, PSSA and other assessment scores, attendance and discipline data, Promise eligibility, credit count, and graduation rates.
IF YOU DO NOT WANT THIS INFORMATION SHARED WITH YOUTHPLACES, please contact Tylor Hart, Program Assistant, Out-of-School Time for Pittsburgh Public Schools at firstname.lastname@example.org or 412-529-3537 and your child’s name will be placed on an opt-out list and no student data will be shared.
The Family Educational Rights and Privacy Act (FERPA) protects you and your child’s right to privacy and confidentiality of educational records. Pittsburgh Public Schools provides you with a detailed written notification of these rights annually and you may always access this notice via the Department of Education link here: http://www.ed.gov/policy/gen/guid/fpco/ferpa/index.html. FERPA requires prior consent to share personally identifiable information. Therefore, the District has developed this Release and Authorization form for its Community-Based and Faith-Based After-School Partners.
Academic Information Release
- I authorize my Child’s School District to provide information and educational records of my child to YouthPlaces. The following information may be released: student ID numbers, attendance, discipline, grades, test scores, citizenship marks, credit count (high school only), Pittsburgh Promise eligibility, and graduation attainment. This Authorization and Release shall remain in effect for one calendar year from the date of my signature.
- Please complete section below to acknowledge parent review and authorization.
I authorize the use of my child’s likeness in media or print YouthPlaces staff documents activities through various mediums such as photographs and videos. Please indicate if images of your daughter/son can be used to promote YouthPlaces’ mission on our website and social media spaces.
In case of an emergency, I authorize a representative of YouthPlaces to seek and agree to medical treatment for my child on my behalf.
If medical attention had to be rendered which hospital would you prefer like the youth to go to.
I give permission for YouthPlaces to transport my child in an authorized YP van or bus for following reasons: field trips (with permission slips), transportation to and from program site and partner program sites, emergency purposes, and any reasons deemed necessary by program.
I acknowledge that I have received and read the YouthPlaces’ behavior policies and procedures for attending the program. All youth enrolled are expected to follow YouthPlaces rules, expectations and consequences attached to this form. Rules and expectations can also be found on our website at www.youthplaces.org.
I acknowledge I have received and read the YouthPlaces’ activities description and service plan.
YP will keep doing our part to prevent the spread of illness by taking everyday preventive actions such as staying home when sick, covering coughs, washing hands often with soap and water, and routinely cleaning frequently-touched surfaces and objects.
Please select all acknowledgments above, to qualify your student for summer camp at YP.
***Parent/Guardian Signature Required***
- I hereby release, forever discharge, and hold harmless YouthPlaces (YP) and its officers, agents, volunteers and employees, from and against any and all claims, demands, or causes of action of any type whatsoever, including property damage, personal injury, or death, arising out of or in any way related to me or my child’s participation in, or affiliation with, YP. I agree that my child and I will not hold YP or any of its affiliates responsible for any injury to me, my child, or my property as a result of attending or traveling to and from such programs and activities. I understand that YP does not carry or maintain health, medical, or disability insurance coverage for any volunteer or participant. By signing this document I acknowledge my understanding of the terms and provisions of this waiver. I also understand that all parties acknowledge and agree that my signature shall be considered legally binding. I agree that this waiver is intended to be as broad and inclusive as permitted by the governing laws, and that this waiver shall be governed by and interpreted in accordance with the laws of Allegheny County, PA. I also agree that in the event that any section of this waiver shall be held to be invalid by any court or competent jurisdiction, the invalidity of that section shall not affect the remaining sections of this waiver.
By inputting your name, you are attesting to the fact that all information in this registration is true.
This field is for validation purposes and should be left unchanged.