AtlantiCare School Based Youth Service Programs/SBYSP
CONSENT TO PARTICIPATE IN SOCIAL SERVICES

The goal of the AtlantiCare School Based Youth Service Programs/SBYSP located in Atlantic City High School, Buena Regional Middle & High Schools and Oakcrest High School, is to promote healthy adolescent development by providing a comprehensive array of services to students during their school day.

Services provided include:

Educational Enrichment	Job Readiness & Preparation	Outreach & Referral Services
Mentoring	Preventative Health Care Education	Recreation

This program requires yearly parent/guardian consent for participation and will expire June 30th of the current school year.

Student Name

Date of Birth

My students attend:

Atlantic City High School

Buena Regional High School

Buena Regional Middle School

Oakcrest High School

CONSENT FOR SOCIAL SERVICES

I grant permission to AtlantiCare to inquire about my child’s needs for the purposes of providing social services. I consent to services provided by AtlantiCare staff and/or staff contracted by AtlantiCare to provide services. I understand that this consent applies to all subsequent visits, unless I revoke my consent.
Confidentiality of all communication between AtlantiCare staff and student is protected by AtlantiCare’s ethical standards and will be released only with student permission in accordance with Federal laws and state regulations, including if they threaten to seriously hurt their self or someone else or if physical/sexual abuse of a child is disclosed.
All services are voluntary. Students and families may use as many or as few services as desired.

While I consent to having AtlantiCare staff provide services to my child, I do not want my child provided with the following service(s):

PARENT/GUARDIAN SIGNATURE

DATE

PARENT/GUARDIAN EMAIL

I would like to receive emails regarding upcoming School Based Youth Service Program events.

For any questions about the AtlantiCare School Based Youth Service Programs, please contact:

Atlantic City Teen Center	acteencenter08401@gmail.com	(609) 345-8336
Buena Youth & Teen Centers	teencenter@buena.k12.nj.us	(856) 697-2400 x8234
Oakcrest Teen Center	ohsteencenter@gehrhsd.net	(609) 909-2677

Media Permission

I hereby grant permission to AtlantiCare, its employees and assigns and/or outside media to photograph, videotape or interview me and/or my dependent(s).

I do not grant AtlantiCare permission to photograph, videotape or interview me and/or my dependent(s).

Student Name

If Subject is a Minor: Name of Parent or Guardian

Parent or Guardian Signature

Date

The specific information AtlantiCare can releases to traditional and new media and through other AtlantiCare communications channels includes:

Photos/Video

Story/Testimonial

Interview

In my participation in the Teen/Youth Center programs and activities:

I understand that the photographs, video, audio, or interview shall become the property of AtlantiCare and/or outside media and organizations and that I shall not have any rights to the same. I also understand that I will not be compensated for participating in the taking of photographs; video, audio and other recordings; or interviewing and that I will not be entitled to compensation as a result of the broadcast or publication of the information.

I understand that the photographs, video or interview may be used and redisclosed as a press release and shared with media for possible publication or broadcast. I also understand that the photographs; video; audio and other recordings; and/or interview might be publicized or broadcast, or used in promotional and informational materials that include, but are not limited to, brochures, billboards, advertisements, the AtlantiCare Internet and Intranet sites, Facebook and any and all other social media and traditional media and publicity and marketing and communications venues. I understand that the information, photographs, audio, video, and/or interview might be edited and I agree that AtlantiCare, its employees and/or agents shall have the right to, at any time, add to, edit, arrange, rearrange and/or revise such information, photographs, video or interview. I understand that AtlantiCare maintains the right to reuse the information, photograph, video, or interview for future purposes without additional authorization or release.

I release AtlantiCare, its employees and agents from any and all claims and from all liability including, without limitation, claims for libel, invasion of privacy and/or misappropriation of likeness arising out of the interviewing, photographing or videotaping and subsequent publication or broadcasting of this material. I understand that I am not required to sign this authorization and that AtlantiCare will not condition treatment on my execution of this authorization. I understand that I have the right to revoke this authorization at any time prior to AtlantiCare’s compliance with the request. The revocation must be in writing and is subject to terms described in AtlantiCare’s Notice of Privacy Practices and other AtlantiCare policies.

I understand that the terms of this authorization are governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other applicable state and federal regulations and that the information disclosed by this authorization may be redisclosed by the recipient and will no longer be protected by HIPAA. This authorization will expire 12-31-2125.