Step 1 of 5 20% Assurance of Insurance / Parent or Guardian Informed Consent:Parent/Guardian Name(Required) First Last Youth Name(Required) First Last Consent(Required) I, as the parent/guardian, agree to the following statement:Depending on the career exploration opportunity, the Student and Parent/Guardian understands that the student may perform functions that could involve risk or injury as if s/he were an employee. I, as the parent or guardian, recognize that in case of injury to my child, the cost of treatment is my responsibility and not the responsibility of the Empower Youth Network (EYN). I also recognize that EYN does not carry primary medical insurance for such injuries and is not responsible for any costs relating to treatment. I understand that I am responsible for providing adequate medical coverage in the event my child is injured while participating in a Path Finder career exploration opportunity. I will notify EYN immediately if there is a change in medical coverage during my child’s participation in any Pathways to Employment Success Path Finder opportunity.Please check the appropriate statement below:(Required) Yes, I have adequate insurance coverage No, I do not have insurance but will still be responsible for the cost of any and all treatment my child may require as a result of participation in a Pathways to Employment Success Path Finder opportunity. I understand that it is not the responsibility of EYN if I choose not to have insurance coverage for my child. Medical Insurance Policy(Required)Medical Insurance Number(Required)Dental Insurance Policy(Required)Fill in as N/A if do not haveDental Insurance Number(Required)Fill in as N/A if do not haveParent Consent(Required) I understand and accept the above statements.Youth Consent(Required) I understand and accept the above statements. Injury Risk / Parent or Guardian Informed Consent:Consent(Required) I, as the parent/guardian, agree to the following statement:I, as the parent or guardian), acknowledge EYN and the work site will strive to ensure the safety of my child while participating in any Pathways to Employment Success Path Finder opportunity, but there are certain inherent risks involved that may be unavoidable and that could result in bodily injury or property damage to my child or to others. I acknowledge that my child is responsible for following the directions of their advisor, work site supervisor, mentor, as well as all safety guidelines in place at the job or career exploration opportunity site. And that my child’s failure to follow such directions or adhere to such standards may place my child at risk. I am fully aware of the special risks and/or dangers inherent in my child’s participation in these types of programs and that it is in a true working environment. I understand and accept the above statements. I hereby give consent for my child to participate in the Path Finder exploration opportunity.Parent Consent(Required) I understand and accept the above statements.Youth Consent(Required) I understand and accept the above statements. Consent to Treatment / Parent or Guardian:Consent(Required) I, as the parent/guardian, agree to the following statement:In the event of illness or accident, I understand reasonable efforts will be made to immediately contact my child’s parents/guardians or emergency contact. I authorize EYN or the Path Finder exploration opportunity organizer to secure emergency medical care as needed for my child on my behalf. This includes all medical, surgical, diagnostic and hospital procedures as may be performed or prescribed by a treating physician for my child if I cannot be reached in the case of an emergency. I agree to be responsible for the cost of any medical services and to reimburse EYN or the Path Finder exploration opportunity organizer for medical expenses they incur on behalf of my child.Any special medical conditions that the Path Finder exploration opportunity organizer should be aware of, and conditions that might restrict or prevent my child from participating in scheduled exploration opportunity activities:(Required)Treatment restrictions / Allergies / Medications:(Required)Child’s physician name(Required) First Last Child’s physician phone(Required)Hospital or facility where i prefer my child be taken in case of an emergency:(Required)Parent Consent(Required) I understand and accept the above statements.Youth Consent(Required) I understand and accept the above statements. Transportation Acknowledgement & Plan:Consent(Required) I, as the parent/guardian, agree to the following statement:I acknowledge that transportation is my/my child's responsibility, to and from the Path Finder opportunity, for my child during his/her participation. I acknowledge that EYN is not responsible for providing transportation as part of the Path Finder opportunity and will not assume responsibility nor liability for any accident or injury involving my child, in any way, on account of or while engaged in travel to or from any Path Finder opportunity. of my child.Transportation Plan(Required)Please write out the transportation plan for your child to and from his/her Path Finder exploration opportunity: (Example: They will take the meteor bus, or we will drop off and pick up, etc)Parent Consent(Required) I understand and accept the above statements.Youth Consent(Required) I understand and accept the above statements. Empower Youth Network’s Pathways to Employment Success program’s Path Finder tool allows teens to connect with and find relevant volunteer opportunities, job shadowing experiences, internships, apprenticeships, local and appropriate jobs for teen students, a network of career mentors, and access to additional career exploration resources. Path Finder is a self-directed, on-line portal for youth to explore careers, learn about education options, identify ideas for employment and job opportunities, and find support through a variety of resources including individual professionals and organizations. Youth safety is Empower Youth Networks (EYN) top priority. The resources included have been reviewed by EYN staff, individual professionals/career mentors have applied and completed a background check, and the organizations offering exploration opportunities comply with the agreement provided by Empower Youth Network to ensure a safe environment for youth to experience and realize their professional capacities, interests, and future goals while learning valuable employability skills. Having carefully read Empower Youth Networks Pathways to Employment Success Path Finder information that includes career exploration opportunities and experiences, the Student and Parent/Guardian understand and agree to accept the following guidelines and responsibilities: The Path Finder is a self-directed tool/resource to promote and encourage career exploration for youth, and to learn independence, increase responsibility, and build employability skills toward future employment goals. When taking advantage of a Path Finder opportunity or experience offered: Communication within the Path Finder tool between youth and career mentor or potential exploration opportunity is monitored by EYN. It is the responsibility of the youth and career mentor/organization to conduct any continued communication/interaction outside of the Path Finder tool in a professional manner at all times. Transportation to and from any on-site exploration opportunity or experience is your responsibility - follow your transportation plan and be mindful of pick-up times. Comply with all requirements agreed upon including attendance and notify prior to any schedule changes or absence. Complete all required forms. Be professional, honest, have a cooperative attitude, proper grooming/dress, willingness to learn and be on time. Familiarize yourself and adhere to all rules, safety guidelines, regulations, policies, and procedures, including any confidentiality requirements. Be fair, considerate, trustworthy, and cooperative when dealing with others. Accurately document the opportunities and experiences for your records. Report any on-site problems to direct contact. Ask questions, seek feedback, and do your best work. Consult with EYN’s Pathways to Employment Success program coordinator about any concerns or problems in a timely manner. I release the Empower Youth Network from all liability on my and my child's behalf, and assume all risks of participation, including travel to and from any Path Finder activity or event. I understand and accept the above statements. Parent Consent(Required) I understand and accept the above statements.Youth Consent(Required) I understand and accept the above statements. Δ
