Consent for Services, Release of Claims and Media Release

Please initial or check the following and sign at the bottom of the page. As used in all remaining parts of this document, the term “I” or “my” refers to the participant referenced below and, if signed by the parent/guardian, also refers to the parent/guardian (as well as the participant). If you are age 17 or younger, a parent or guardian signature is also required to confirm their agreement on behalf of the participant.
This document is being provided in connection with the services, activities, and programs (collectively, “Services”) offered by Bethany Christian Services of Michigan, a Michigan nonprofit corporation (“Bethany”) related to the Grand Rapids Center for Community Transformation (“GRCCT”). If you have any questions about the following, please ask a staff member to explain. In this document, the term “Services” will refer to the services, activities and programs offered by Bethany at or in connection with the GRCCT.
INDIVIDUALIZED SERVICE PLAN: You have the right to be involved with developing an individual service/activity plan that identifies what Services you will engage in and how those Services address your needs and goals. The plan will be reviewed periodically with you and/or your parent/guardian.
VOLUNTARY PARTICIPATION AND WITHDRAWAL OF SERVICES: You have the right to ask questions and to be informed regarding any Services in which you are asked to participate. You have the right to decline Services and terminate your involvement at any time without fee or penalty.
GRIEVANCES: If you have a concern about the Services or decisions made about you—you (or a parent/ guardian if allowed by law) may discuss the matter informally with the program manager or director of programming. You may also submit your concern in writing. If not resolved, you may present the grievance to the next level personnel.
Consent to Participate and Release of Claims: I consent to participate in the Services provided by Bethany. I am aware that there are potential hazards and risks involved. I am willingly consenting to participate in all aspects of the Services (including, but not limited to, field trips, transportation and the paid work experience). I hereby release and discharge Bethany and the other Released Parties (as such term is defined below) from and against any and all claims, damages and liabilities arising out of or related to the Services or the GRCCT, including without limitation any personal injury or death. This release applies regardless of any negligence or other wrongful conduct of Bethany or any of the other Released Parties. I assume all risks associated with the Services or the GRCCT. I make this release knowingly and voluntarily. I agree that the above release is intended to be as broad and inclusive as permitted by the laws of the State of Michigan and that, if any portion of this release is held invalid, the remaining part of this release will continue in full force and effect. I irrevocably and unconditionally waive my rights to a trial by jury in any action that arises out of or relates to this release or the Services by Bethany or any other Released Parties. As used above, the term “Released Parties” refers to Bethany, its affiliates (including Bethany Christian Services, a Michigan corporation, and all other parent companies, subsidiaries and other related companies) and all of its and their respective officers, directors, employees, agents, representatives and volunteers.
Consent to Participate in Surveys & Data Collection: I give my consent to complete surveys during participation in Services. Bethany collects surveys to understand the experience of participants and the effectiveness of Services. Bethany also shares responses with a third-party evaluator. Appropriate protocol is followed to ensure the privacy and confidentiality of all program participants including using a Unique ID instead of names to identify surveys.
Survey participation is NOT required to receive Services and you may choose at any time to not finish the survey.
Incentive & Gift Card Agreement Statement: I agree than any check or gift card I receive from Bethany will not to be used to purchase alcohol, firearms, tobacco, or entertainment. I also agree that I will not redeem gift cards received from Bethany for cash.
Consent to Media Release: Bethany and its affiliates use story, photos, and video to describe its services in educational, informational, and promotional materials. I grant permission to Bethany and its affiliates to use my story, photos and/or video about myself in their materials and in all mediums. I waive the opportunity and right to inspect or approve any such information or materials used for any purpose in all mediums (i.e., print, electronic, video, web, social media) except for any restrictions I’ve listed below. I release Bethany and the other Released Parties (as such term is defined above) and those acting under Bethany’s authority from all claims and liabilities of any kind arising from the use of my information. None of my information (story, photo(s), or video) will be released to a third-party organization without written consent from me.
The following information applies only to youth participating in the Love Notes® curriculum
Love Notes Curriculum Overview and Consent: Love Notes is evidenced-based curriculum staff utilize to help youth build skills and knowledge for healthy and successful relationships for romance, friends, family, school, and work. We use an innovative strengths-based approach that teaches youth about forming and maintaining healthy relationships. This approach empowers youth to further their own personal development, to form and maintain healthy relationships, and to make wise sexual decisions.

The Love Notes curriculum covers a lesson which discusses pregnancy, STI, and HIV avoidance.
I have reviewed and acknowledge the Love Notes Curriculum overview and I consent to participate in all lessons of this curriculum.
COVID-19 Risk Acknowledgement and Agreement: Bethany requests all program partners and participants to follow COVID-19 safety precautions and applicable Executive Orders while engaging in Bethany Services. Nevertheless, the agency cannot prevent participants from possibly being exposed to, contracting, or spreading COVID-19 while participating in any of our Services.
This agreement constitutes notice of the particular risk of being exposed to or contracting COVID-19. Bethany disclaims all liability, on its own behalf and on behalf of its employees, worksite employers, and Board members for any damage of any kind arising out of a participant’s voluntary activity and employment experience.
I agree that:
1.I understand the risks of participation, including those risks related to COVID-19;
2.Despite the risks above, I have voluntarily and freely decided that I will take part in Bethany’s Servicesif eligible;
3.I will follow all COVID-19 related rules and expectations for Services, including those related to self-screenings, face coverings, hygiene, contact tracing, social distancing, testing, and immediate site pickup (due to illness) if/when applicable. I authorize my temperature to be taken when applicable.
4.If I display any symptoms of COVID-19 or are exposed to the virus, I understand I am restricted fromany Services and will notify Bethany staff immediately
Youth Services Consents, Releases, and Agreements Packet | 3
5.If doing so is in the worksite or agency’s best interest or in the interest of public health, I may temporarilyor permanently be suspended from my participation in Services. When applicable, Bethany staff willassist me in making up missed classes as a result of COVID-19.
6.I can choose to opt out of Services at any time. If I choose to opt out of an employment experience orthe employment experience has been terminated, there is no guarantee I can return to the employmentsite or be provided a new placement.
7.I have had the opportunity to consult with a health care provider of my choice and after suchconsultation or after declining to engage in such consultation, I have determined that participating in theemployment experience is advisable based on my unique circumstances.
8.I have read the terms of this agreement, I understand the terms, and I freely and without duress agreethat I will be bound to them.
1.Notice of Client Rights
2.General Notice of Privacy Practices
3.HIPAA Notice of Privacy Practices
4.Consent to Receive Email and Text Messages
Acknowledgement of Receipt: I acknowledge and agree that I have received the above documents of Bethany Christian Services, its affiliates, subsidiaries, and related entities.
Email and Text Message Consent: I consent to communication by text and/or email from Bethany related to its services, including communicating with my Bethany staff person, receiving survey invitations, or getting appointment reminders. I acknowledge that I have read and understand the risks listed below and understand that standard text messaging rates may apply to any text messages sent to or received from Bethany. I understand that I can opt-out of receiving text and/or email messages in the future. I understand that some of the risks involved in email and text message communication include, but are not limited to:
•Individuals who have access to devices on which I download messages or to my email or text messageaccount could view the messages that Bethany sends to me. If I receive emails or texts on equipmentowned by my employer, my employer may have a right to inspect emails and texts sent through itssystems.
•Messages may not be encrypted, which means that if they are intercepted, they could be read andcirculated by others.
•Senders can misaddress an email or text and send information to an undesired recipient.
•My email or texting service may have a right to inspect messages sent through their service and maykeep backup copies, which may continue to exist even after I have deleted my copy. A copy may alsocontinue to exist on Bethany’s system.
•During transmission, emails and texts could be intercepted, altered, forwarded or used withoutauthorization or detection.
•Emails and texts may be used as evidence in court.
I consent to Bethany communicating with me via email using the email address(es) I provide to Bethany
I consent to Bethany communicating with me via text messaging using the mobile phone number(s) I provide to Bethany:
Your choice as to whether to receive text and/or email communications will not affect your ability to obtain continued or future services through Bethany, but it may hinder our ability to communicate with you.
By signing below, I acknowledge that I have read, understood, and accurately responded to each section of this document.
Signature (If the participant is younger than 18, a parent or guardian signature is required) *