West Patton City Youth Leadership Collaborative
239 Main St.
West Patton City

Consent for Release of Information

I hereby grant permission for

(Name of releasing organization or individual) to release to (Name of responsible person) of the West Patton City Youth Leadership Collaborative any and all information collected concerning me during my enrollment in or work with (the releasing organization or individual) __________ from (date)_____ to (date)_____. I also grant permission for (the releasing organization or individual) to discuss with the above-named responsible person any information that would be helpful to the WPCYLC in providing services to me.

Alternatively, I give permission only for the release of the material circled below.

Records Written notes Taped notes Test results Verbal discussion

Other (please specify) _____________________________

I understand that the West Patton City Youth leadership Collaborative and its employees may not release this information to any other organization or individual without my permission.

Printed name______________________________________________________

Signature________________________________________ Date__________

For WPCYLC:

Printed name_______________________________________________________

Signature________________________________________ Date__________

West Patton City Youth Leadership Collaborative
239 Main St.
West Patton City

Informed Consent Form

I understand that by agreeing to take part in the programs of the West Patton City Youth Leadership Collaborative (WPCYLC), I also understand and agree to the following:

1. All information, conversation, records, test results, and any other material related to my participation in WPCYLC will be kept strictly confidential. It will not be released to any other organization or individual without my permission EXCEPT

a. If it contains evidence of current or potential child abuse or neglect;

b. If it contains evidence of potential harm to me or others;

c. If it is required as evidence in a court case.

2. If I feel that I have been unfairly or unlawfully treated or deprived of services by WPCYLC, I may take advantage of the organization's grievance procedure by informing the Director that I wish to file a grievance. I have received a copy of WPCYLC's grievance procedure, and it will be explained to me again at the time that I request to file a grievance. I may seek help filling out forms for the grievance procedure from someone of my choice. I may be accompanied at any meeting or hearing of the grievance procedure by someone of my choice, who may speak or negotiate in my behalf if I designate him or her to do so.

3. I will not appear at any meeting, class, field trip, or other activity of the WPCYLC under the influence of alcohol or any controlled substance.

4. I will not smoke during any meeting, class, field trip or other WPCYLC activity.

5. I agree to inform WPCYLC of any change of address for five years after I leave the program, and to be contacted up to once a year for that period for purposes of follow-up.

Printed Name _________________________________

Signature _____________________________________ Date __________

For WPCYLC:

Printed Name _________________________________

Signature _____________________________________ Date __________

CARE Consortium Conflict of Interest Disclosure Form

The Ryan White HIV CARE Consortium has members who are professionally or personally affiliated with organizations that have received, or may request or receive funds authorized under Title I and/or Title II of the Ryan White CARE Act. Because of the potential for conflict of interest, this Disclosure Form has been adopted by the Consortium and must be completed by all current members and candidates for membership in the Consortium.

By my signature below, I certify that:

(1) I have received, read, and understood and will abide by Sections 3.1 through Section 3.4 of the Consortium's Bylaws; and

(2) I am serving (or have served within the past twelve months) in a staff, consultant, officer, board member or advisor capacity with the following organization (s) that receives, has received or plans to seek funding under Title I or Title II of the Ryan White CARE Act of 1990.

_______________________________________________________________________

Name of Consortium Member

_______________________________________________________________________

Organization

_______________________________________________________________________

Title of Position

_______________________________________________________________________

Period of Affiliation

(3) A member of my family is serving (or has served within the past twelve months ) in a staff, consultant, officer, board member or advisor capacity with the following organization(s) that receives, or plans to seek funding under Title I or Title II of the Ryan White CARE Act.

_______________________________________________________________________

Name of Family Member

_______________________________________________________________________

Relationship

_______________________________________________________________________

Organization

_______________________________________________________________________

Title of Position

_______________________________________________________________________

Period of Affiliation

_______________________________________________________________________

Name of Family Member

_______________________________________________________________________

Relationship

_______________________________________________________________________

Organization

_______________________________________________________________________

Title of Position

_______________________________________________________________________

Period of Affiliation

_______________________________________________________________________

(Attach additional pages if necessary.)

_______________________________________________________________________

Consortium Member (Print your name)

_______________________________________________________________________

Signature

_______________________________________________________________________

Date