Consent Form

I know what Back2Back Cincinnati is providing to me, to my student and/or my family. I give permission for the following family members to participate in Back2Back Cincinnati activities. I understand this includes but is not limited to coaching, educational guidance, therapeutic support, group activities, and care coordination. I understand Back2Back Cincinnati will store all personal information and program documents in a confidential manner. I understand myself and/or my student will go on outings with Back2Back Cincinnati, and I give permission for myself and/or my student to be transported to and from these outings in Back2Back staff members’ personal vehicles.

Coaching Communication(Required)

I give permission for my student to communicate with their coach via Facebook Messenger for mentorship purposes.

Yes

No

N/A

Contacting Student(s)(Required)

I give permission for Back2Back Cincinnati staff to contact my student via text messages and phone calls.

Yes

No

N/A

Guardian Information

Name(Required)

First Last

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Student Information

Name of Student 1(Required)

First Last

Phone(Required)

Birthday(Required)

School and Grade(Required)

Guardian Signature (If student is under 18)(Required)

Date(Required)

Student Signature (If over 18)

Date

Consent Form Addendum: Additional Students Covered

Name of Student 2

First Last

Phone

Birthday

School and Grade

Name of Student 3

First Last

Phone

Birthday

School and Grade

Name of Student 4

First Last

Phone

School and Grade

Birthday

General Field Trip and Transportation Permission Form

Student 1(Required)

First Last

Student 2

First Last

Student 3

First Last

Student 4

First Last

Student 5

First Last

General Field Trip Permission(Required)

I give permission for the above students to participate in walking and driving field trips to the following locations from Back2Back Cincinnati Communities of Belonging: Saturday Hoops, Cincinnati Rec Center, Echo Park, and the Incline District.

Yes

No

Transportation Permission(Required)

I give permission for the above students to be transported to and from Communities of Belonging in Back2Back Cincinnati staff members’ personal vehicles and/or Back2Back Cincinnati’s vehicles.

Yes

No

Front Seat Permission(Required)

If my student is 13 or over, I give permission for my student to ride in the front seat while Back2Back Cincinnati staff transport my student.

Yes

No

Guardian Signature (If student is under 18)(Required)

Date(Required)

Student Signature (If student is over 18)

Date

Sharing Photos, Videos, and Stories

Participant Name(Required)

Back2Back Cincinnati believes you and your youth own your stories. Back2Back Cincinnati also recognizes the power of shared stories and commits to being a positive platform for your voice if you and your youth desire. In the sharing of your story, Back2Back Cincinnati is committed to honor you and your youth’s right to dignity and privacy. All photos, videos, and stories of you or your youth will be gathered and used with sensitivity and your permission. When using your images or story, Back2Back Cincinnati will not share specific locations or provide detailed information to protect you and your youth’s safety and well-being. I give permission for Back2Back Cincinnati and Back2Back Cincinnati’s partnering organizations to photograph, interview, and record my youth and/or myself. I understand the materials made are the property of Back2Back Cincinnati and Back2Back Cincinnati’s partnering organizations. I understand Back2Back Cincinnati and Back2Back Cincinnati’s partnering organizations may use these materials for promotional purposes with my consent. This could include Back2Back’s or partnering organization’s website, social media sites, newsletters, televised broadcasts, and professional publications. I understand signing this form is voluntary and will not impact Back2Back Cincinnati’s relationship with my youth and our family. I understand I can revoke this consent at any time in writing.

Guardian Signature (If student is under 18)(Required)

Date(Required)

Student Signature (If student is over 18)

Date

Liability Waiver Form

This Release and Waiver of Liability executed on ______________________ (date) by __________________________ (Guardian) and ________________________ (Participant) releases Back2Back Cincinnati, LLC., a nonprofit corporation organized and existing under the laws of the State of Ohio and each of its employees, volunteers and agents. The Guardian approves the Participant’s desire to engage in services and programming with Back2Back Cincinnati. The Guardian and Participant understand that the scope of the Participant’s relationship with Back2Back Cincinnati is voluntary and the Participant can opt-out at any time. The Guardian and Participant are responsible for the Participant’s own insurance coverage in the event of personal injury or illness as a result of participation with Back2Back Cincinnati. 1. Waiver and Release: I, the Guardian, release and forever discharge and hold harmless Back2Back Cincinnati and its successors and assigns from any and all liability, claims, and demands of whatever kind of nature, either in law or in equity, which arise or may hereafter arise from the services provided by the Back2Back Cincinnati. I understand and acknowledge that this Release discharges Back2Back Cincinnati from any liability or claim that I may have against Back2Back Cincinnati with respect to bodily injury, personal injury, illness, death, or property damage that may result from the Back2Back Cincinnati’s programming. 2. Insurance: Further I understand that Back2Back Cincinnati does not assume any responsibility for or obligation to provide me with financial or other assistance, including but not limited to medical, health, or disability benefits or insurance. I expressly waive any such claim for compensation or liability on the part of Back2Back Cincinnati beyond what may be offered freely by Back2Back Cincinnati in the event of injury or medical expenses incurred by me. 3. Medical Treatment: I hereby release and forever discharge Back2Back Cincinnati from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during the Participant’s engagement with Back2Back Cincinnati. 4. Assumption of Risk: Guardian and Participant understand the activities may involve outdoor events, physical exertion, use of mechanical equipment, exposure to hazardous conditions, including transportation to and from the activity sites, or other circumstances that may be hazardous. Guardian hereby expressly and specifically assumes the risk of injury or harm in participation, and releases Back2Back Cincinnati from all liability for injury, illness, death, or property damage resulting from participation. Guardian acknowledges that while the staff and volunteers of Back2Back Cincinnati have been trained to protect emotional and physical safety, participation is purely voluntary. 5. Other: The Guardian and Participant expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Ohio and that this Release shall be governed by and interpreted in accordance with the laws of the State of Ohio. The Guardian and Participant agree that in the event that any clause or provision of this Release is deemed invalid, the enforceability of the remaining provisions of this Release shall not be affected. By signing below, I express my understanding and intent to enter into this Release and Waiver of Liability willingly and voluntarily.

Guardian Signature (if participant is under 18)(Required)

Date(Required)

Student Signature (if over 18)

Date

Participant's Printed First and Last Name(Required)

Date(Required)

Guardian's (If Under 18) First & Last Name

Date

Consent Form

Consent Form

Guardian Information

Student Information

Consent Form Addendum: Additional Students Covered

General Field Trip and Transportation Permission Form

Sharing Photos, Videos, and Stories

Liability Waiver Form

Release of Information

Release of Information (ROI) Consent

Field Trip Consent

Consent Form

Consent Form

Guardian Information

Student Information

Consent Form Addendum: Additional Students Covered

General Field Trip and Transportation Permission Form

Sharing Photos, Videos, and Stories

Liability Waiver Form

Sponsor A Child or Family

Release of Information

Release of Information (ROI) Consent

Take A Mission Trip

Field Trip Consent

Job Inquiry Form

Write A letter

Back2Back Intern Application