Divert Youth Intervention Consent Form Participant: Full Name: Client Date of Birth: Parent/Legal Guardian Name: Program Consent As parent or legal guardian of the juvenile named above, I give consent for my child to participate and I agree to participate as required in the Divert program and activities deemed appropriate for his or her needs. These activities may include, but are not limited to: life skill education classes, drug testing and referral sources. I understand that recommended programs and activities will be discussed and approved by me prior to my child’s participation. Liability/Hold Harmless In consideration for my child’s participation in the Divert program I waive any and all claims against S&T Wecare, and its employees that may be occasioned through his/her participation. I hereby release and hold harmless S&T Wecare, and its and employees should any suit or damages result from any activities or transportation provided to my child. Release/Exchange of Information As parent or legal guardian of the juvenile named above, I give consent for Divert to obtain and release/exchange information regarding my child’s involvement with the program. I agree to sign additional necessary releases as needed in order for my child to participate in this program. I understand that I may revoke this authorization at any time by written request with the exception of information that has already been released. Signatures guardian signature(s) Participant: Parent or legal guardian (s): Parent or legal guardian (s): Witness: (Mentor). Date:
Divert Youth Intervention Consent Form Participant: Full Name: Client Date of Birth: Parent/Legal Guardian Name: Program Consent As parent or legal guardian of the juvenile named above, I give consent for my child to participate and I agree to participate as required in the Divert program and activities deemed appropriate for his or her needs. These activities may include, but are not limited to: life skill education classes, drug testing and referral sources. I understand that recommended programs and activities will be discussed and approved by me prior to my child’s participation. Liability/Hold Harmless In consideration for my child’s participation in the Divert program I waive any and all claims against S&T Wecare, and its employees that may be occasioned through his/her participation. I hereby release and hold harmless S&T Wecare, and its and employees should any suit or damages result from any activities or transportation provided to my child. Release/Exchange of Information As parent or legal guardian of the juvenile named above, I give consent for Divert to obtain and release/exchange information regarding my child’s involvement with the program. I agree to sign additional necessary releases as needed in order for my child to participate in this program. I understand that I may revoke this authorization at any time by written request with the exception of information that has already been released. Signatures guardian signature(s) Participant: Parent or legal guardian (s): Parent or legal guardian (s): Witness: (Mentor). Date: