Youth leadership st. louis

2024-25 Consent Form

If you experience any issues with your form submission, please contact Cate Hanford .

"*" indicates required fields

Student Information

Name*

First Last

Preferred First Name

First

Date of Birth*

Sex*

Male

Female

Prefer Not to Say

Not Listed

Race*

African-American/Black

Asian

Bi-Multi-Racial

Caucasian/White

Hispanic/Latino or Spanish Origin

American Indian/Alaska Native

Middle Eastern/North African

Native Hawaiian/Pacific Islander

Other

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

School/Organization Name*

If "Other" please input the School/Organization name below.

Other School/Org. Name

Parent/Guardian Information

Parent/Guardian #1

Name*

First Last

Address

(If different from student)

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Secondary Phone

Parent/Guardian #2

Name

First Last

Address

(If different from student)

Street Address Address Line 2 City State ZIP Code

Primary Phone

Secondary Phone

Health History

List any health issues (illness/injury) that might affect your child’s ability to fully participate in YLSL.

Indicate any activity to be encouraged or restricted.

List current medications.

(NOTE: YLSL Staff will not administer medications)

Indicate any special dietary needs.

Does your child require any accommodations? If yes, please describe their needs.*

Write N/A if none.

List any known allergies, below, including symptoms and actions that should be taken.

I.e. animals, foods, plants, medicines, etc.

Covid-19 Policy & Procedure

Some spaces, hosts, and/or speakers may require us to demonstrate that the YLSL cohort is vaccinated and/or has a negative Covid-19 test within 24 hours of each program day.

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Has your child been fully vaccinated and/or received their booster shot?*

If answering "no" please proceed to the next question.

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Will your child be fully vaccinated or boosted by the YLSL Opening Retreat?

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Proof of Vaccination

If applicable, please upload a photo or scanned copy of your child's completed Covid-19 vaccination record.

Drop files here or

Max. file size: 50 MB.

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Permission to Share

I give program staff permission to share proof of my child's vaccination or negative test with the host organization in accordance with their policy.

Yes

Emergency Contacts

Emergency contacts should be available throughout the program year and in the event that parents/guardians are unreachable.

Emergency Contact #1

Name*

First Last

Relationship to Student:*

Primary Phone*

Emergency Contact #2

Name

First Last

Relationship to Student:

Primary Phone

Child's Physician

Name*

First Last

Phone*

AUTHORIZATION TO SECURE PROPER MEDICAL TREATMENT AND RELEASE OF LIABILITY*

I certify that the health history given above is true and correct to the best of my knowledge. My child may participate in all activities except as noted above.

In the event of an emergency medical situation occurring during my absence or when hospital/medical authorities are unable to contact me, I hereby give permission to the physician selected by the Director of the Youth Leadership St. Louis program (or other authorized representatives), to hospitalize, secure proper treatment for and order injection, anesthesia, and/or surgery for my child. I recognize that I will be responsible for any costs incurred for medical treatment administered to my child.

On behalf of myself and my child, I hereby release and discharge FOCUS St. Louis, Youth Leadership St. Louis, its affiliates, and all employees, agents, representatives, and volunteers (individually and collectively) from any and all liabilities, claims, damages, losses and expenses of any kind, which may be asserted by me or my child, arising from/relating to my child’s participation in the Youth Leadership St. Louis program.

I have read and agree to the above authorization and release of liability.

Electronic Signature*

First Last

2024-25 Youth Leadership St. Louis Parent/Guardian Consent

Parent/Guardian Email Information

YLSL staff will use parent/guardian's email as the primary mode of communication to provide updates, agendas, and additional information for program days. If you do not have an email address, you may create one for free at www.gmail.com.

Parent/Guardian #1 Email*

Enter Email Confirm Email

Parent/Guardian #2 Email

Enter Email Confirm Email

PARENT PARTICIPATION CONSENT/HOLD HARMLESS AGREEMENT*

I expressly release and agree to indemnify and hold FOCUS St. Louis (hereafter "FOCUS) its directors, officers, employees, and agents free and harmless from any and all liability, charges, claims, costs, and expenses of every kind and nature whatsoever, including reasonable attorney fees, in connection with this activity, on behalf of myself and my child.

I agree to the consent and hold harmless agreement.

Parent/Guardian Initials*

MEDIA PERMISSION*

I hereby give FOCUS permission to use my child's name, likeness, image, and/or voice in photography or video recordings (online or in-person) taken as a part of his/her participation in YLSL. I understand that these images and recordings may be used for promotional purposes in print and digital publications, including but not limited to, newsletters, brochures, social media, reports, and other related materials. I hereby release FOCUS and its legal representatives for all claims and liability relating to said images and waive my child's right to any compensation.

Yes

Parent/Guardian Initials*

VIRTUAL CONSENT*

I understand that in-person experiences will supported through virtual platforms. I hereby give my child permission to participate in YLSL’s virtual distance learning program through which staff will facilitate activities using software, tools, and applications provided by third parties which include, but are not limited to: Zoom, Mentimeter, and Flipgrid. I understand that YLSL does not have control of third-party platforms. Parents/guardians are strongly encouraged to monitor the online activities of their child to ensure safety when not engaging in YLSL.

Yes

Parent/Guardian Initials*

PERMISSION TO SURVEY*

I understand that my child will be asked to participate in pre/post-program evaluations and program day surveys as part of YLSL to measure program benefits and impact. I understand my child’s participation is voluntary; s/he/they will neither receive compensation of any form for participating nor will his/her/their standing in YLSL be affected if s/he/they chooses not to participate. I understand that his/her/their confidentiality will be protected.

Yes

Parent/Guardian Initials*

PARENT/GUARDIAN AGREEMENT*

I have read and understand the YLSL Health Form, Participant Agreement, and Parent Consent Form. I may change or revoke any aspect of this agreement at any time by submitting my request, in writing, to the YLSL Director at FOCUS St. Louis, 815 Olive Street, Suite 110, St. Louis, MO 63101.

Parent/Guardian #1 Electronic Signature*

First Last

Date*

Parent/Guardian #2 Electronic Signature

First Last

Date

2024-25 Youth Leadership St. Louis Student Participant Agreement

This section is to be reviewed and completed by the YLSL participant.

The purpose of YLSL is to inform, connect, prepare and empower St. Louis area youth to become civic and community leaders. Every participant, together with program staff and advisors, contributes to the success of this program. Below, is an outline of expectations that we ask of all participants, advisors, and program staff.

Program Staff and Advisors commit to:

Respectful and effective communication with all participants and their parents/guardians.

Maintain a safe and fun learning experience.

Address problems that are brought to our attention.

Create an environment where everyone is welcomed and given the opportunity to succeed.

As a participant in the YLSL program for 2024-2025, I agree to attend all program days, participate with an open & curious mind and respect the diversity of ideas & experiences of others. The conduct policies of my school/community organization apply to this program, including, but not limited to: policies related to student/member codes of conduct and school closure due to inclement weather conditions. Any additional policies and expectations specific to YLSL are listed below and will be discussed at the opening retreat and subsequent program days as needed.

Program Expectations

Treat my fellow participants, program advisors and YLSL staff with respect.

Plan ahead for personal needs so that I can participate fully and on time in all activities.

Challenge myself to learn and advocate for my needs, including, requesting help or accommodation when I need it.

Be an active bystander: do what I can to help others or find assistance when needed.

Refrain from engaging in bullying, inappropriate conversation or posting inappropriate visuals at any time.

Follow staff, volunteer and guest instructions and raise concerns respectfully.

Complete assigned individual and group assignments on time.

Contribute ideas and adhere to a youth-driven community agreement to be designed at Opening Retreat,

Program Expectations*

I, the student, agree to meet the above program expectations.

Participant Email Information

YLSL staff will use email as the primary mode of communication to provide updates, agendas, and additional information for program days. If you do not have an email address, you may create one for free at www.gmail.com.

Student Email*

Enter Email Confirm Email

PARTICIPANT AGREEMENT*

I have read and understand the aforementioned Participant Agreement.

Student's Electronic Signature*

First Last

Date*