Consent Form (Page 2): Club Program
INFORMED CONSENT – PROVISION FOR SERVICE and CONFIDENTIALITY
INFORMED CONSENT - PROVISION FOR SERVICE:
I, , parent/guardian of hereby provide my consent for my child to participate in Boys & Girls Clubs Big Brothers Big Sisters of Edmonton & Area programs, including drop in, registered based programs, and recreational activities, whether these programs occur at a club or an outside program location (i.e. – school gym or field trip). I agree that it is my responsibility to get my child to and from the club/program location.
I am fully aware and agree to the following:
- In the event that programs change, my child becomes ill or a behavioural issue arises with my child, I am able to pick my child up or my child is able to walk home immediately.
- I agree that the program is drop-in, and it is my responsibility to clearly communicate with my child and staff my rules for their comings and goings at the program. In collaboration with staff, we will work to ensure the safety of my child during program hours.
I understand that my child may, from time to time, participate in programs away from the club/program location, including field trips, and that my child may be transported by Boys & Girls Clubs Big Brothers Big Sisters of Edmonton & Area staff or volunteers for the purpose of participating in these programs and/or field trips. A separate consent form will be sent home for these special events.
I agree that Boys & Girls Clubs Big Brothers Big Sisters of Edmonton & Area will not be responsible for any injuries my child may sustain from/while participating in any Boys & Girls Clubs Big Brothers Big Sisters of Edmonton & Area programs and/or field trips whatsoever, or while on Boys & Girls Clubs Big Brothers Big Sisters of Edmonton & Area property.
I authorize the senior staff member present with my child to seek medical attention for my child in the event of an injury or sickness.
In consideration for this service and other valuable consideration provided to my child by BGCBigs, I release the agency of all responsibilities and liabilities in connection to their services provided in good faith, to myself or my child. I permit the agency to release any relevant information, including my personal information, to Big Brothers Big Sisters of Canada and their insurers, as may be appropriate in connection with any legal proceeding, inquiry or risk thereof.
Without limiting the generality of the foregoing, my participation in in-person meetings in connection with my involvement with the Agency exposes me to certain risks, including the risk of contracting Covid-19 which may result in serious illness or death. I assume all risks associated with therewith including the risk of contracting Covid-19 and hereby release all The Agency, BBBSC/BGCC thereto.
I agree to work in partnership with the staff and volunteers of Boys & Girls Clubs Big Brothers Big Sisters of Edmonton & Area to deal with any behavioural issues concerning my child. I understand that all data collected will adhere to Freedom of Information and Protection of Privacy Act and Personal Information Protection Act.
I agree that my child will participate in a Safety Training Program offered by Boys & Girls Clubs Big Brothers Big Sisters. The Safety Training Program is designed to:
- Develop a children’s sense of personal space, privacy and comfort.
- Empower a child to act in positive ways to assert their rights.
- Enhance a child’s risk assessment, problem solving skills, and personal safety skills.
- Contribute to a child’s self-esteem so that they are equipped to protect themselves.
- Provide children with the knowledge and tools for abuse prevention.
CONFIDENTIALITY: The Agency believes in maintaining high standards of ethical conduct in the operation of the agency’s programs and the representation of them to the community, including a commitment to privacy and confidentiality within the limitations defined by law. The Agency adheres to all applicable Federal and Provincial Privacy legislation and is committed to protecting the professional and personal privacy and confidentiality of its volunteers, youth, and their families.
All individuals in a position of trust within the agency are required to sign a privacy/confidentiality agreement. This includes staff and volunteers. It is important to understand that information will be shared with other staff only as needed for service to your child or family. Care will be taken that information to any involved professional outside of the agency is only released if relevant only to the agent’s specific needs and as necessary for the best care of the child or his/her family, and only with the signed consent of the family except in the case of concern of child abuse or neglect, where staff are required by law to inform the proper authorities, which could result in the disclosure of confidential information. If subpoenaed to a trial, hearing or proceeding, Agency staff members are again required by law to disclosure. The names of the children and/or their parents concerned in any judicial proceeding shall not be shared outside the agency
CONFIDENTIALITY AGREEMENT
I, , parent/guardian of , have read the BGCBigs statement on confidentiality and do understand and agree.
CONSENT FOR AUDIO / VISUAL RECORDING
On occasion, your child’s photo may be taken in relation to their participation with BGCBigs. These photos may be used in promotional materials and advertisement including brochures, posters, newsletters, media information, advertisements, audio-visual productions and web pages, such as the Agency website and social media. Photographs or video productions may also be shared with community and school partners for program promotion.
I, , parent/guardian of provide consent that my child can be photographed, videotaped or recorded in conjunction with programs of BGCBigs and further agree that materials produced as a result are the property of BGCBigs (indicate yes or no below).