ROI Hamilton County Juvenile Court

Release of Information

Name of Participant(Required)

Release of Information (ROI) Consent

I understand my student’s story and/or my story is ours to share. I understand Back2Back Cincinnati will hold our information confidential unless necessary by law. I realize Back2Back Cincinnati can better serve my student and/or our family when they communicate to other individuals working with my student and/or our family. I give permission for Back2Back Cincinnati to give and receive information in regards to my student(s) and/or myself from Hamilton County Juvenile Detention Center (20/20), Hamilton County Juvenile Probation, Hamilton County Public Defender’s Office, Hamilton County Diversion Court Programs, Hamilton Prosecutor’s Office, and Hamilton County Juvenile Court.
Consent(Required)
Name of Consenting Guardian or Student (if over 18)(Required)
Submitting your name below as a digital signature, you are acknowledging any release of information and understand that the permission can be revoked at any time by contacting Back2Back Cincinnati in written format either in email or letter.
Provide the date of consent and submission of this form.
MM slash DD slash YYYY

Sponsor A Child or Family

Release of Information

Name of Participant(Required)

Release of Information (ROI) Consent

I understand my student’s story and/or my story is ours to share. I understand Back2Back Cincinnati will hold our information confidential unless necessary by law. I realize Back2Back Cincinnati can better serve my student and/or our family when they communicate to other individuals working with my student and/or our family. I give permission for Back2Back Cincinnati to give and receive information in regards to my student(s) and/or myself from Hamilton County Juvenile Detention Center (20/20), Hamilton County Juvenile Probation, Hamilton County Public Defender’s Office, Hamilton County Diversion Court Programs, Hamilton Prosecutor’s Office, and Hamilton County Juvenile Court.
Consent(Required)
Name of Consenting Guardian or Student (if over 18)(Required)
Submitting your name below as a digital signature, you are acknowledging any release of information and understand that the permission can be revoked at any time by contacting Back2Back Cincinnati in written format either in email or letter.
Provide the date of consent and submission of this form.
MM slash DD slash YYYY

Take A Mission Trip

Student Name(Required)
Additional Student Name
Parent/Guardian Name(Required)

Field Trip Consent

Please provide consent or deny consent for the following planned field trip. A Yes or No response is required for every field trip. "Yes" indicates consent while "no" will result in a denial of consent and your student will not be able to participate in the activity.
Newport Levee | Monday 6/10/24 | 2:30-4:30(Required)
One Levee Wy, Newport, KY 41017 | Pick Up at 2:30 pm, Drop Off at 4:45 pm
Mt. Echo | Monday 6/17/24 | 2:30-4:30(Required)
251 Mt Echo Park Dr, Cincinnati, OH 45205 | Pick Up at 2:30 pm, Drop Off at 4:45 pm
Dunham Pool | Monday 6/24/24 | 10-2(Required)
4356 Dunham Ln, Cincinnati, OH 45238 | Pick UP: 9:45 Drop OFF: 2:15 | Swimsuit Required
Kings Island | Monday 7/1/24 | 10-3(Required)
6300 Kings Island Dr, Mason, OH 45040 | Pick UP: 9:45 Drop OFF: 3:15
French Park | Monday 7/8/24 | 2:30-4:30(Required)
3012 Section Rd, Cincinnati, OH 45237 | Pick UP: 2:15 Drop OFF: 4:45
FC Cincinnati Game | Saturday 7/13/24 | 7:30-9:30(Required)
1501 Central Pkwy, Cincinnati, OH 45214 | Pick UP: 7 Drop OFF: 10
Washington Park | Monday 7/15/24 | 2:30-4:30(Required)
1230 Elm St, Cincinnati, OH 45202 | Pick UP: 2:15 Drop OFF: 4:45
Smale Riverfront Park | Monday 7/22/24 | 2:30-4:30(Required)
166 W Mehring Way, Cincinnati, OH 45202 | Pick UP: 2:15 Drop OFF: 4:45
Mt. Echo | Monday 7/29/24 | 2:30-4:30(Required)
251 Mt Echo Park Dr, Cincinnati, OH 45205 | Pick Up at 2:30 pm, Drop Off at 4:45 pm
Spruce Nails | Monday 8/5/24 | 2:30-4:30(Required)
1818 Race St Suite 101, Cincinnati, OH 45202 | Pick UP: 2:15 Drop OFF: 4:45 | Your student will be getting their nails painted
Digital Signature of Consenting Guardian or Student (if over 18)(Required)
By filling out your name as the parent, guardian, or consenting student (if over 18) below, you are signing in agreement with Back2Back's ability to take your child on extracurricular activities. This digital signature serves as an additional form of consent along with the choices above.
Date of Submission(Required)
This field is for validation purposes and should be left unchanged.

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