YOUTH RELEASE FORM - ABADÁ-Capoeira San Francisco

2024-2025 Youth Release Form

Youth Ages (5 to 19). Please complete all fields and provide a valid and active email address below.

NEED FINANCIAL ASSISTANCE? *

For qualifying families ABADA-Capoeira San Francisco Reaching All Youth Program (RAY) Project. If interested, please select "yes" below and we will be in touch with details.

NO, Thank You!

YES

Participating Youth's Full Name *

Youth's date of birth *

(mm/dd/yy)

Youth's Gender *

The child identifies their gender as…

Male

Female

Prefer not to disclose

Prefer to describe below...

Youth's Primary Home Address *

Country

City

State

Zip code

Youth's Phone Number, if applicable

Current School: *

Grade: *

Preferred Language Spoken At Home: *

How would you describe or identify yourself?

If none of the above options fit your race/ethnicity. (Please specify)

Please provide following information for the parent(s), caregiver(s) the youth lives with:

1st Parent/ Guardian Name: *

(First and Last)

Relationship: *

Profession:

Primary Phone *

Email *

This is the primary way we will communicate with you regarding your child's participation in our programs and important updates.

2nd Parent/ Guardian Name:

(First and Last)

Relationship:

Profession:

Primary Phone

Home address if different from above:

Country

City

State

Zip code

In case we cannot get a hold of you in an emergency, who should we contact? *

(First and Last Name)

Relationship:

Phone

MEDICAL INFORMATION

Any physical/medical conditions that we should be aware of? *

Medication(s):

Allergies that we should be aware of? *

NONE

YES

If YES, Please specify

INSURANCE INFORMATION

Family Doctor’s Name:

Phone:

Insurance Carrier:

Insurance #:

Has the youth had previous experience with Capoeira? *

If yes, where? With whom? For how long?

IT IS SUGGESTED THAT ALL STAFF AND STUDENTS BE VACCINATED AGAINST COVID-19

We strongly recommend that everyone keep their Covid-19 vaccinations up to date. While masking is optional, we ask that all students remain mindful of the health risks. If you experience any cold or flu symptoms, please stay home to protect others.

RELEASE AND WAVE AGREEMENT (Read & Agree)

By checking the box below, I, the undersigned, agree to the following terms and conditions for my child’s participation in activities with ABADÁ-Capoeira San Francisco (ACSF).

PHOTOGRAPHY WAIVER *

I hereby give permission for my child to be photographed, videotaped, and/or interviewed for ABADÁ-Capoeira San Francisco (ACSF) in promotional materials.

YES

BEHAVIOR EXPECTATIONS *

Participation is contingent upon students following ACSF’s expectations and exhibiting positive behavior. Students who do not follow these guidelines may be suspended or removed from the Capoeira Classes.

YES

GENERAL WAIVER *

I will inform my child about safety protocol to ensure they are understood and followed. I accept that there are potentially serious risks and dangers inherently associated with the activities, and I know it is important that no students do anything they consider unsafe. I have instructed my child accordingly. ACSF directors and staff work to ensure the safety of participants and are trained in first aid techniques and to follow established emergency procedures. I understand that there may still be risks and dangers beyond their control, and I accept full responsibility for any losses or damages to me or my child, however caused or alleged to be caused. I intend my signature to be a complete and unconditional release from liability to the full extent allowed by law.

YES

RELEASE OF LIABILITY *

I hereby release (for myself, my executors, and administrators) and waive any and all rights to claims for damages arising from any illness, accident, or occurrence caused by or as a result of my child's participation or connection with ACSF, its instructors, agents, representatives, and/or facilities. ACSF, its agents, instructors, representatives, and facilities shall not be held responsible by me for the loss or theft of my child's belongings. I have been warned that my child must be in good health to participate in this program, and I now declare that my child is in good health. I declare that I have read and understood the foregoing statement and that I have either consulted a physician for my child or voluntarily chosen not to consult a physician before starting or during the course of this program.

YES

STUDENT SAFETY & CONDUCT *

Students are not supervised when they are not in class. They are responsible for their own safety and their own belongings. Students must respect the space, ACSF staff, and other students, and remain quiet and respectful of any class that is in progress. There are NO DRUGS, NO ALCOHOL, NO WEAPONS of any kind allowed in the studio at any time. Any member who brings weapons, drugs, or alcohol into the studio or comes to the studio under the influence of drugs or alcohol will be removed from the program. ACSF is a safe space, and anyone who violates or jeopardizes the safety of the facility will be removed from the program.

YES

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL STUDENT INFORMATION | DCYF

The San Francisco Department of Children, Youth, and Their Families (DCYF) funds our agency and the services we provide. To fulfill the requirements of this funding, we share information about the participants in our services with DCYF. DCYF and the San Francisco Unified School District (SFUSD) maintain a shared, secure database to record information about services provided to San Francisco youth by DCYF’s grantees in order to facilitate outreach and enrollment, and track program use and impact. As a DCYF grantee, our agency has access to this shared database to both see and report data about the youth we serve. The data that we report to DCYF is also shared with SFUSD.

1) Our agency to share information about your child’s participation in our program (or your participation, if you are 18 years of age or older) with authorized staff at DCYF and SFUSD for the purposes described above. The information that our agency reports to DCYF includes:

Personal information, such as name, date of birth, and address;
Demographic information, such as race/ethnicity and gender identity;
Education information, such as school name and grade level;
Participation in activities and services, such as dates of attendance and hours attended;
Anonymous and voluntary youth experience surveys.

2) SFUSD to share certain information about your child (or you, if you are 18 years of age or older) with authorized staff from our program as a DCYF grantee. The information that SFUSD reports to DCYF includes:

Personal information, such as name, date of birth, and address;
Education information, such as school name and grade level;
Dates of attendance in SFUSD or an SFUSD school.

3) Confidentiality and Data Use:
DCYF, SFUSD, or our agency will not publicly report any information that we provide in a way that may be used to identify your child (or you, if you are 18 years of age or older).

4) Restrictions:
All information related to an SFUSD student is protected by federal and state laws that govern the use, disclosure, and re-disclosure of student education records. No party other than DCYF, SFUSD, and our agency will have access to personally identifiable information reported into the database, except where the parties have obtained prior written authorization from you or have followed SFUSD policies and procedures to access such information.

5) Expiration:
This authorization expires on June 30, 2029.

6) Your Rights:

You may refuse to sign this form.
You may cancel it at any time by informing our agency in writing. If you cancel your permission allowing us to release information to DCYF and SFUSD, and SFUSD to our agency, it will go into effect immediately unless the information has already been released.
You have the right to receive a copy of this form.

Can we share your information with DCYF? *

(Please select "Yes" or "No")

YES

Youth’s full name *

Youth’s Signature *

I, (Participant Legal Name), promise to take care of my property and to show respect for myself, the building, other participants, and the staff at all times while participating in ABADÁ-Capoeira San Francisco (ACSF) programs and activities. I understand that if I fail to adhere to these rules and principles, I may be suspended and/or expelled from ACSF’s facility and its programs. I recognize the importance of maintaining a positive and respectful environment for all involved, and I commit to upholding the behavior expectations set by ACSF. By signing below, I acknowledge and agree to these terms.

Reset Signature

Signature is required.

Relationship to Participant:

Parent

Legal Guardian

Participant 18 Years of Age or Older

Parent or Guardian’s Signature *

I, (Parent or Guardian Legal Name), understand and agree that my child’s participation in ABADÁ-Capoeira San Francisco (ACSF) programs is contingent upon their adherence to ACSF’s expectations and the demonstration of positive behavior. I give my permission for Child to participate in any activities at ACSF. I/we have been informed of ACSF’s rules and regulations, and we agree to comply with these policies. I acknowledge that ACSF staff reserves the right to suspend or expel a student at any time if these guidelines are not followed. If my child is over the age of sixteen, I understand that they may sign their own form and do not require parental permission to participate. By signing below, I affirm that I have read, understood, and agree to the terms outlined above for my child’s participation in ACSF programs.

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e-Signature Instructions:

*Hold down your left mouse button and drag the cursor to add your signature from your computer or just sign using your finger on your smartphone or tablet.