YOUTH RELEASE FORM - ABADÁ-Capoeira San Francisco

ACSF Youth Release Form 2023-2024

Youth (up to 19 yrs) Participant Release Form & Reaching All Youth (RAY) Project Application. Please complete all fields and provide a valid email address.

NEED FINANCIAL ASSISTANCE? Would you like to be considered for financial assistance through our Reaching All Youth (RAY) program? *

Families in-need may receive FREE access to classes throughout the school-year and discounted rates are available for Summer Camp. If interested, please select "yes" below and we will be in touch with details.

YES

Participating Youth's Full Name *

Youth's date of birth *

(mm/dd/yy)

Youth's Gender *

The child identifies their gender as…

Male

Female

Prefer not to disclose

Prefer to describe below...

Youth's Primary Home Address *

Apt, suite, etc.

Country

City

State

Zip code

Youth's Phone Number, if applicable

Type:

Cell

Work

Home

Current School: *

Grade: *

Preferred Language Spoken At Home: *

Please Specify

How would you describe yourself? (specify)

Please provide following information for the parent(s), caregiver(s) the youth lives with:

1st Parent/ Guardian Name: *

(First and Last)

Relationship:

Profession:

Primary Phone *

Alt Phone

Email *

THIS IS THE PRIMARY WAY WE WILL COMMUNICATE WITH YOU REGARDING YOUR CHILD'S PARTICIPATION IN OUR PROGRAMS. Please provide a valid/active email. We will never sell or misuse your information.

2nd Parent/ Guardian Name:

(First and Last)

Relationship:

Profession:

Primary Phone

Alt Phone

Home address if different from above:

Apt, suite, etc.

Country

City

State

Zip code

In case we cannot get a hold of you in an emergency, who should we contact? *

(First and Last Name)

Relationship:

Phone

Other (specify)

MEDICAL INFORMATION

Any physical/medical conditions that we should be aware of?

Medication(s):

INSURANCE INFORMATION

Family Doctor’s Name:

Phone:

Insurance Carrier:

Insurance #:

IT IS SUGGESTED THAT ALL STAFF AND STUDENTS BE VACCINATED AGAINST COVID-19

Please let us know if you are vaccinated by listing your vaccination dates.

1st

Vaccination Date

2nd

Vaccination Date

Booster

Vaccination Date

Booster

Vaccination Date

Has the youth had previous experience with Capoeira? *

If yes, where? With whom? For how long?

RELEASE AND WAVE AGREEMENT

(Read & Agree)

I hereby give permission for my child to be photographed, videotaped and/or interviewed for use by ABADÁ- Capoeira San Francisco (ACSF) in promotional materials. *

YES

I hereby give permission for my child to participate in scheduled activities and performances that occur off-site at nearby facilities (parks, schools, etc.). *

I understand that transportation will be provided and that my child will be accompanied by a staff person. I understand that ACSF staff will supervise all activities. For any special events or field trips, I will receive a separate permission slip in advance.

YES

I hereby give my consent to have my child treated by a physician or surgeon in case of sudden illness or injury while participating in an ACSF program. *

It is understood that the cost thereof will be at my expense. To protect the safety of staff and our members and reduce liability, ACSF staff does not dispense or store medication of any kind for our participants.

YES

ACSF will only supervise youth in the building during class times. I am solely responsible for my child's transportation to and from ACSF's studio location. *

YES

I hereby release (for myself, my executors and administrators) *

and WAIVE any and all rights to claims for damages arising from any illness, accident, or occurrence caused by or as a result of my child's participation or connection with ACSF, its instructors, agents, representatives, and/or facilities. ACSF, its agents, instructors, representatives, and facilities shall not be held responsible by me for the loss or theft of my child's belongings. I have been warned that my child must be in good health to participate in this program and I now declare that my child is in good health. I declare that I have read and understood the foregoing statement and that I have either consulted a physician for my child or voluntarily chosen not to consult a physician before starting or during the course of this program.

YES

Students are not supervised when they are not in class. *

They are responsible for their own safety and their own belongings. Students must respect the space, ACSF staff and students, and remain quiet and respectful of any class that is in progress. There are NO DRUGS, NO ALCOHOL, NO WEAPONS OF ANY KIND allowed in the studio at any time. Any member who brings weapons, drugs, or alcohol into the studio or comes to the studio under the influence of drugs or alcohol will be removed from the program. ACSF is a safe space. Anyone who violates or jeopardizes the safety of the facility will be removed from the program.

YES

DCYF

The San Francisco Department of Children, Youth, and Their Families (DCYF) funds our agency and the services we provide. To fulfill the requirements of this funding, we share information about the participants in our services with DCYF.

DCYF and the San Francisco Unified School District (SFUSD) maintain a shared, secure database to record information about services provided to San Francisco youth by DCYF’s grantees in order to facilitate outreach and enrollment and track program use and impact. As a DCYF grantee, our agency has access to the shared database to both see and report data about the youth we serve. The data that we report to DCYF is also shared with SFUSD. By signing this form, you authorize 1. Our agency to share information about your child’s participation in our program (or your participation, if you are 18 years of age or older) with authorized staff at DCYF and SFUSD for the purposes described above. The information that our agency reports to DCYF includes: • Person information, such as name, date of birth, and address: • Demographic information, such as race/ethnicity and gender identity; • Education information, such as school name and grade level; • Participation in activities and services, such as dates of attendance dates and hours attended; and • Anonymous and voluntary youth experience surveys. 2. SFUSD to share certain information about your child (or you, if you are 18 years of age or older) with authorized staff from our program as a DCYF grantee. The information that SFUSD reports to DCYF includes: • Personal information, such as name, date of birth, and address; • Education information, such as school name and grade level; and • Dates of attendance in SFUSD or an SFUSD school. DCYF, SFUSD, or our agency will not publicly report any information that we provide in a way that may be used to identify your child (or you, if you are 18 years of age or older). Restrictions: All information that we provide or access that is related to an SFUSD student is protected by federal and state laws that govern the use, disclosure and re-disclosure of student education records. Parties other than DCYF, SFUSD and our agency will not have access to any personally identifiable information that is reported into the database, except to the extent that the parties have obtained prior written authorization from you or have followed SFUSD policies and procedures to obtain access to such information. Expiration: This authorization expires on June 30, 2024. Your Rights: You may refuse to sign this form. You may cancel it at any time by information our agency in writing. If you cancel your permission allowing us to release information to DCYF and SFUSD, and SFUSD to our agency, it will go into effect immediately, unless the information has already been released. You have a right to receive a copy of this form.

Youth’s full name *

has my permission to participate in any activities at ACSF. I/she/he/they has/have been advised regarding ACSF's rules and regulations, and we agree to comply with these policies.

Relationship to Participant:

Parent

Legal Guardian

Participant 18 Years of Age or Older

e-Signature Instructions:

*Hold down your left mouse button and drag the cursor to add your signature from your computer or just sign using your finger on your smartphone or tablet.

Participant’s Signature *

(participant legal name) I promise to take care of my property, and to respect myself, the building, other participants and staff at all times. I understand if I do not abide by these rules and principles, I will be suspended and/or expelled from ACSF's facility and its programs.

Reset Signature

Signature is required.

Parent or Guardian’s Signature *

(Parent or Guardian legal name /Name Signature Agreement) Participation is contingent upon student\'s following ACSF's expectations and exhibiting positive behavior. ACSF staff reserves the right to suspend or expel a student at any time if those guidelines are not followed. Youth over sixteen years of age may sign their own form and do not need parental permission.

Reset Signature

Signature is required.