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Today's Date: January 19, 2021

 

Dear Parent/Guardian,

Your child has been invited to participate in the Living Skills Program at their school or community program! Through a variety of discussions, activities, and games your child will build new connections with peers and learn important skills for:

  • Cooperation
  • Problem Solving
  • Expressing Feelings
  • Creating Healthy Friendships
  • Valuing Differences
  • Managing Stress

This small group of 6 to 8 youth will meet weekly or bi-weekly for up to 10 weeks. The group sessions last for 30 minutes to an hour and are held during the regular school day or as part of an after school program.

This group may be offered to your child through live video conferencing on the Zoom platform. The group facilitator will host “meetings” through their Zoom account and will invite youth to join the meeting through a student email or parent/guardian email. You and your child will not need a Zoom account, but you will need access to the internet and a computer, phone, or tablet. Our commitment to keeping the young people we serve safe is always our number one priority. We will actively monitor youth activity on Zoom and will make every effort to protect youth through the use of Meeting Waiting Rooms, Locked Meeting Rooms and other safety tools provided in the platform. You can review Zoom’s privacy terms and conditions here: http://zoom.us/terms and http://zoom.us/privacy

Please give your consent to the statement below and complete this short registration form if you would like your child to participate. If you have any questions, please contact the program director at the number below.

Sincerely,

Volunteers of America, Utah Prevention Services

(801) 364 – 0744 x122

 

 

 

I hereby give my informed consent for my child to participate in the Volunteers of America, Utah Living Skills Program. I understand that this program is voluntary and that my child is not required to participate. I understand that my child may be pulled from their class during school hours for group sessions. I give permission for my child to meet via Zoom live video conferencing. I acknowledge/understand the potential risks, consequences, and limitations of digital supportive services and voluntarily assume them in the hopes my child is obtaining the desired beneficial results:

  • Digital supportive services are relatively new and therefore lack research indicating that it is an effective means of receiving support.
  • Participants lack visual and/or audio cues, which may increase the likelihood of misunderstanding each other.
  • Digital support may have disruptions or delays in the service and quality of the technology used.
  • In rare cases, security protocols could fail and your confidential information could be accessed by unauthorized persons.

I give permission for the group facilitator to talk with my child’s teacher, school counselor, and/or program director about their progress in the program. I understand that my consent can be withdrawn at any time by notifying the group facilitator by phone and that my consent will expire when the program ends.

I Agree

Please select who will be participating...
Minor
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First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
Gender*

Please specify a gender identity not listed...
Race / Ethnicity *
Hispanic / Latino (of any race)
Native American / Alaskan Native
Native Hawaiian / Pacific Islander
White / Caucasian
Black / African
Asian
Bi-Racial or Multi-Racial
Race / ethnicity not listed here

Please specify a race/ ethnicity not listed...

Child's School *
Grade*

Child's Student Email *

Child's Phone Number (if applicable)
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Parent or Guardian's Phone Number

Phone Number *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Gender*

Please specify a gender identity not listed...
Race / Ethnicity *
Hispanic / Latino (of any race)
Native American / Alaskan Native
Native Hawaiian / Pacific Islander
White / Caucasian
Black / African
Asian
Bi-Racial or Multi-Racial
Race / ethnicity not listed here

Please specify a race/ ethnicity not listed...

Child's School *
Grade*

Child's Student Email *

Child's Phone Number (if applicable)
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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