Permission Slip

Youth Name: ____________________________________________

Date of Birth: ______________________

 New Haven Youth & Family Services, Inc. frequently incorporates therapeutic & educational recreational activities on a daily, weekly, and monthly basis as a part of their behavioral health services.

 

The following is an example of some typical activities:

  • Roller skating, Roller blading and Skateboarding (with appropriate gear)
  • Bicycling
  • Recreational Team Sports (ex. soccer, flag football, basketball, volleyball)
  • Skiing and/or Snowboarding
  • Swimming, Boat Trips, and Other Water-related Activities
  • Laser tag and/or Paintball
  • Trail Walks and Hiking
  • Camping  

RELEASE AND CONSENT FORM

I give my child permission to participate in all recreational, educational, and therapeutic activities sponsored by New Haven Youth & Family Services, Inc. I hereby, for myself, my heirs, executors, administrators and assigns, waive and release any and all claims for damages I may have against New Haven Youth & Family Services, Inc., their representatives, and/or employees arising out of any and all injuries to my child while they are a resident at New Haven Youth & Family Services.  I fully understand what is involved, and I understand that I may contact the Program Specialist at any time prior to any activity, with any questions that I may have.   Additionally, I may verbally withdraw consent for any one or more activities on a case-to-case basis.

PLEASE INITIAL BELOW TO GRANT CONSENT FOR THESE INDIVIDUAL EVENTS 

(      ) Religious-sponsored Events: Frequently, local churches sponsor non-religious activities, festivals, and concerts. By initialing this box, I give my permission for my son to attend events put on by or sponsored by religious organizations.

(         ) Photo Release: By initialing this box, I hereby grant to any employee, representative, and agent of New Haven Youth & Family Services, Inc. the right to photograph and/or record the image and/or voice of my child and use said information for publication purposes whether digital, electronic, or print.

(          ) Limits & Restrictions       ________________________________

 

_______________________________________/ _________________

Signature of Parent, Guardian, or Authorized Representative/ Date

 

_______________________________________/ _________________

Signature of NHYFS Representative or Witness/ Date