Child Centered Family Program Participant Form

Children's Program Participant Form

Thank you for your interest in our Child-centered Family Program! This form should be completed by a parent or guardian on behalf of the child(ren) who will be participating in the program. Please answer any questions as completely as you can and carefully read through the forms before signing. You may request a copy of this form for your own records.
Today's Date

MonthDayYear
Date
For this section, please provide information about the adult who will be participating in the program as the child's safe adult. Please remember you must have legal authority to consent to the child's participation in this program.
Your name *

First NameLast Name
Your email*
example@example.com
Your phone number
Please enter a valid phone number.
Your mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your relationship to child*
Who referred you to this program?
Information on child (or children) who will participate in program*
Please describe family history of alcoholism and/or other drug addiction
Is the child aware of the family member(s) addiction?
Yes or no is fine but if there are other details you think are relevant, please let us know.
Please list any family members who are currently in recovery?
What is the status of the child's parents' relationship?
Who has custody of the child?
Please list name and relationship to child.
How frequent is visitation with non-custodial parent?
Describe any history of abuse or neglect (physical, sexual, verbal):
Does the child have any problems or particular strengths in school?
Please describe any health concerns the child may have including allergies, mental health concerns, physical health concerns or recent injuries.
Name of the child's primary medical provider?

First NameLast Name
Phone Number of child's primary medical provider.
Please enter a valid phone number.
Will your child need to take any prescribed medications during the hours of 8 am to 3 pm during the four-day program?
Please list any medications
Please describe any major life changes within the past year for your child (death of person or pet, separation, moves, major illness of child or someone close to child, etc)
Please describe any history of counseling or therapy the child has experienced.
What are your hopes for this program? How do you hope it will benefit the child and you?
Authorization and Release

I voluntarily consent to allow the child or children listed in this application to participate in the Hanley Foundation Children's Program. I further voluntarily consent and agree to participate myself. I am aware that participation in the Children’s Program involves certain activities (such as physical activities including swimming) which are physically demanding and potentially dangerous for children. I am aware that these activities involve a potential risk for illness and injury to my child and property. I acknowledge that I am aware of and assume all risks and wish to allow my child to participate in the activities. I acknowledge that I am responsible for informing Children's Program staff of any allergy, injury, or other physical or mental health condition that might be relevant to my child's or children's participation in the program.As part of the consideration for my child’s participation, I agree to assume full responsibility for any loss, injury, or inconvenience that my child might suffer. To the extent that I participate in such activities, I further agree to indemnify and hold harmless Hanley Foundation and all its subsidiaries and officers from any and all liability incurred as a result of participation by myself or my child. I also agree that the terms hereof shall serve as a release and assumption of risk for my heirs, executors and administrators, and for all members of my family.
I have legal authority to consent to the above and I do so voluntarily.*

I agreeI do not agree
Authorization to treat a minor

In the event I cannot be reached in an emergency, I hereby give permission to the person named as emergency contact to authorize medical and hospital care of my child and if such person cannot be reached, I give permission to the physician on-call at the treating Medical Center to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for my child(ren) as named above. I give permission for Hanley Foundation staff or any treating medical provide to contact the primary medical provider listed above in order to coordinate care for the child(ren) listed in this application.
I have legal authority to consent to the above and I do so voluntarily.

I agreeI do not agree
Authorization to transport a minor

I understand that participation in the Children's Program will involve my child(ren) being transported by motor vehicle from the Hanley Resource Center to the Hanley campus. I authorize this transportation.
I have legal authority to consent to the above and I do so voluntarily.

I agreeI do not agree
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Children's Program Participant Form

For this section, please provide information about the adult who will be participating in the program as the child's safe adult. Please remember you must have legal authority to consent to the child's participation in this program.

Authorization and Release

Authorization to treat a minor

Authorization to transport a minor