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* 1. Participant Contact 

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* 2. Pronouns

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* 3. Parent/Guardian & Emergency Contact Information

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* 4. Medical Information:
Parents/Guardians: Please list any allergies to drugs, foods, insect bites, etc. that your youth has. Please, also list any medications your youth is taking and additional comments.

Applicants 18 years and older: Please list any allergies to drugs, food, insect bites, etc. that you have. 

Use N/A if not applicable.

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* 5. Information Provided:

The contact information above is correct and to the best of my knowledge. I authorize CHC to call 911 or seek other emergency services on behalf of myself (if applicant is 18 years and older) or the youth listed above (if applicant is a minor). I understand that both the Lock It UP Project and the California Health Collaborative nor its insurance carrier is liable for any medical or hospital costs incurred by the applicant and, therefore, I agree to remain fully liable and responsible for the payment of any such costs. This consent and release is binding on my successors and assigns, and it is continuous and may not be revoked.

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* 6. Media Release Form:

On behalf of myself (if applicant is 18 years and older) or the program participant (if applicant is a minor), I hereby consent and give permission to participate in interviews, the use of quotes/name, photographs, video and audio recordings by the California Health Collaborative (CHC)-Lock It Up Project. I also grant the right to edit, use and reuse said products for non-profit purposes including but not limited to print publications, including website, and all other forms of media. I hereby waive any right to inspect or approve the photographs, publications or electronic matter what may be used in conjunction with them now or in the new future, whether that use is known or unknown to me. I also hereby release the California Health-the Lock It Up Project and its agents and employees from all claims, demands and liabilities whatsoever in connection with the above.

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* 7. Transportation and Liability Release Form:

I give permission to myself/my child to participate this year's 2020-2021 California Health Collaborative-C.A.L.I. Youth Coalition. I agree I will not hold the California Health Collaborative and/or its programs Department of Behavioral Health, and/or my child's school, their employees, or agents responsible for any injury or sickness myself/my child may incur during this program.

I also confirm my decision listed above to "give consent/not give consent" (check one) to the California Health Collaborative program staff to provide transportation for me/my child to participate in program related events/activities. Transportation includes but is not limited to private vehicle, rental vehicles, or bus. I understand and acknowledge that participation in the program involves inherent risks of injury to myself/my child including risks associated with transportation by motor vehicle. I release the California Health Collaborative and/or its programs, Department of Behavioral Health, and or my child's school, their employees, or agents responsible and their affiliates from liability for injury or damages which may result from myself/my child's participation in this program.

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* 8. Agreement:

Parents/Guardians-I, Parent/Guardian of applying youth, agree that my child can participate in the program and represent the California Health Collaborative-C.A.L.I. Youth Coalition. I have fully informed myself of the contents of this parent/guardian agreement and release form for all activities listed above by reading it before checking the appropriate box indicating "I agree". I warrant that I possess all the rights, powers, and privileges of a parent or legal guardian necessary to execute this document with binding legal effect.

Applicants 18 years and over: I, the applicant, have fully informed myself of the contents of this agreement and release form for all activities listed above by reading it before checking the appropriate box indicating "I agree". I warrant that I possess all the rights, powers, and privileges as someone 185 years and older necessary to execute this document with binding legal effect,

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* 9. Applicant Agreement:

I, as the applicant, am aware of the duties and qualifications required to be part of the C.A.L.I Youth Coalition. I understand my responsibility as a C.A.L.I. Youth member. I will attend meetings and activities that I am required to attend unless otherwise notified, or in case of emergency or illness. I understand that it is my responsibility to ask for additional information from program staff if I need it.

I will represent the program and agency to the greatest of my abilities, be respectful to the program staff or I will lose my privilege to participate int he program. 

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