Eligibility Form

Please acknowledge each term and sign below

I/we, the undersigned, individual and as parent(s) and or legal guardian(s) of THE YOUTH LISTED ON THIS FORM, a minor, give permission to participate in the youth program. In consideration of this participation, I/we do hereby agree to release, discharge, and hold harmless Sacramento Youth Center & its partner organizations , and employees of and from all causes, liabilities, damages, claims, or demands whatsoever on account of any injury or accident involving the said minor arising out of my child’s participation in the program/project activities.
I understand that participation in this program does NOT guarantee a stipend and this is not a paid position.

I/we grant permission to Sacramento Youth Center, and/or its agents or employees to use photographs and/or video taken of my child during this program for use in promotional and educational materials and to use such photographs/video in electronic versions of the same publications or on organization sites or other electronic forms of media, and to offer them for use or distribution in other media outlets, electronic or otherwise, without notifying me. I hereby agree to release, defend, and hold harmless and its agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper, via electronic media, or on Web sites, from and against any claims, damages, or liability arising from or related to the use of the photographs/video.

All data obtained from your child will be kept confidential and will be used by staff to increase the quality of the program. However, data will be shared with all program partners. Survey forms completed by your child will not include identifying information and data gleaned from them will only be reported when included in combined group results only. Individual data may be used to support program staff become more aware of the unique strengths and challenges of your child, allowing them to tailor and improve the program to meet their specific needs. The data collected will be stored in a HIPPA-compliant online server. Participation in this evaluation is completely voluntary. You have the right to withdraw your child from the evaluation at anytime or refuse to participate entirely without jeopardy to your status in the program. If you desire to withdraw, please contact Adam Shipp. If you have any questions about program evaluation, you may contact Adam Shipp at 925-550-9673. I have read and understand this consent form and I agree to allow my child to participate in this study.


To continuously serve youth safely in light of COVID-19 safety protocols, this organization may provide distance learning activities in which staff facilitate program activities through an online platform. Virtual Programming will be scheduled in advance and parents/guardians are permitted to join and observe meetings in which their child is in attendance. Two adults, including one Program staff/volunteer will always be on the sessions . Please read the following and submit the form to register consent for your child(ren)’s participation in virtual Programming. I fully understand that the program involves Partner Staff who shall be selected from the community and will be screened and trained before beginning in the program. Staff will actively engage my child in a real-time, live setting, online via Zoom and/or the equivalent online service.

I, the parent or legal guardian, hereby give my permission for my child(ren) to participate in virtual/online programming.

The primary purpose of the Youth Program Code of Conduct is to ensure the safety and well-being of all participants in the program. As a participant in this program, youth will be asked to abide by the following guidelines:

Conduct themselves in a courteous manner and treat members, parents, volunteers, staff, and others with respect. Appropriate language and behavior are expected at all times.

Respect and adhere to the rules and guidelines of the program including all those specific to this project.

Uphold an individual’s right to dignity by supporting an environment of inclusion which welcomes involvement of participants from all backgrounds.

Obey local, state, and federal laws.

Participants who fail to adhere to the Youth Program Code of Conduct are subject to dismissal from the program.

I/we understand the code of conduct that will be expected of all program participants.

I have read and checked the terms listed above:
-Permission and Liability Release
- Media Release
- Program Evaluation & Confidentiality
- COVID-19 Terms
- Youth Program Code of Conduct

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