Parent Authorization Form


Your child has requested to stay at the LC Valley Youth Resource Center. Please complete the following form to provide permission for your child to stay at 1633 10th Avenue, Lewiston, Idaho.  Please contact our team at (208) 717-5566 if you have any questions.

Student's Name:

Student's Date of Birth:

Grade:

School:  

Guardian's Name:

Address:

City:  

State:

Postal Code:

Guardian's Phone:

Number of Members in Household:

Please list Student's Medical Conditions:  

Please list Student's allergies:

Special Medication, Blood Type, Pertinent Information:

Student's Physician:

Preferred Hospital:

Consent for Overnight Accommodations
I certify that that I am the parent or legal guardian of the student listed above. I do hereby consent for this student to stay overnight at the LC Valley Youth Resource Center at 1633 10th Avenue, Lewiston, Idaho.

Hours of Operation
I understand the LC Valley Youth Resource Center Inc closes at 8:00 am Monday through Friday and at 10:00 am on Saturday and Sunday.

Transportation
I understand LC Valley Youth Resource Center Inc does not provide transportation. I acknowledge all transportation will be the responsibility of the guardian. If transportation is not available, I grant and authorize LC Valley Youth Resource Center Inc permission to provide bus tokens to the student.

Consent to Release Student
I understand the student listed above has chosen to be present at the LC Valley Youth Resource Center at 1633 10th Avenue, Lewiston, Idaho. I further understand if the student chooses to leave the facility at 1633 10th Avenue, the student will be allowed to leave at any time. If the student chooses not to comply with LC Valley Youth Resource Center Inc safety policies, these actions will be considered a choice not to remain at the LC Valley Youth Resource Center and the student will be required to leave the property. I hereby grant and authorize the LC Valley Youth Resource Center to release the student at any time. The LC Valley Youth Resource Center will not be held responsible for the student once the student leaves the facility at 1633 10th Avenue, Lewiston, Idaho.

Liability Release 

I hereby release, indemnify and hold harmless LC Valley Youth Resource Center, its officers, directors and employees, and the organizers, sponsors and supervisors of all LC Valley Youth Resource Center activities from any and all liability in connection with any injury my child may sustain (including any injury caused by negligence) in conjunction with staying at or departing from the LC Valley Youth Resource Center.

Consent to Treat Minor Child

I certify that that I am the parent or legal guardian of the student listed above. I do hereby consent to any medical care and the administration of anesthesia determined by a physician to be necessary for the welfare of my child while said child is under the care of Michelle King, Edgar King, or Juan Hart of Lewiston Idaho and I am not reasonably available by telephone to give consent. This authorization is effective for 365 days from the signature date on this form.

Authorization for Exchange of Confidential Information with Lewiston Independent School District No. 1 and Clarkston School District.

(This form allows information about your student to be exchanged.)

I authorize Michelle King (President) and Tryston Soderstrom (Case Manager) of LC Valley Youth Resource Center at 1633 10th Avenue, Lewiston, ID 83501 to obtain information from Lewiston High School, Clarkston High School, Jenifer Middle School, Lincoln Middle School, Sacajawea Middle School, Lewiston Independent School District No. 1, and Clarkston School District. By signing this authorization, I understand that the parties named above are permitted to exchange written and verbal information regarding my child with Lewiston Independent School District No. 1 and/or Clarkston School District. This includes official school records, transcripts, teacher/counselor/staff observations, social work reports, and counseling records.

This authorization is for the purpose of providing information for the care of my child at the LC Valley Youth Resource Center.

The parties also accept a photocopy of this release form and give it the same full force and effect as the original. I further understand that I may revoke this authorization in writing at any time by providing a copy of my revocation to the parties named above. The information used or disclosed under this release might be disclosed by the school district as an education record pursuant to FERPA and might no longer be protected by HIPAA.

I give CONSENT for the bidirectional exchange of information.

 

DISCLOSURE: Privacy Notice and Release of Information Authorization

LC Valley Youth Resource Center is an affiliated Service Provider in the Idaho Homeless Management Information System (HMIS). The HMIS lead agency, Idaho Housing and Finance Association (IHFA), administers HMIS, which is a shared homeless and housing information system. HMIS exists in order to aid Continuums of Care in complying with federal program requirements, improving the services and programs made available to individuals (including families), coordinating and evaluating necessary services, and to generate reports that will help communities and care continuums understand the complete extent and impact of homelessness.

The State of Idaho’s HMIS uses the latest and most sophisticated network security systems available to ensure your confidentiality. The information that is collected in the HMIS database is protected by limiting access to the database and by limiting with whom the information may be shared. Every person and service provider that is authorized to read or enter information into the database has signed an agreement to maintain the security and confidentiality of the information. Any person or agency that is found to have violated their agreement may have their access rights terminated, and may be subject to further federal, state, and/or local penalties. This Privacy Notice may be amended at any time and may affect information collected before the date of the amendment.

Any information you provide will not be disclosed to any unaffiliated third party unless authorized by you or required by law. Please read the following statements (or ask to have them read to you), and make sure you have had an opportunity to have your questions answered.

  1. Information you provide will be entered into Idaho HMIS;
  2. Information may be used for reporting, research or functions related to payment or reimbursement of services;
  3. Information you provide will help improve and coordinate services that can be offered you;
  4. Information you provide concerning physical or mental health problems will not be shared with anyone other than the HMIS System Administrator, the COC System Administrator, or this Service Provider, unless authorized by you.
  5. Protected Personal Information will not be disclosed to any Third Party, State, or Federal Agency unless authorized by you except as required by law or to avoid a serious threat to health or safety;
  6. Failure to provide the requested information may limit the Service Provider’s ability to provide services or refer you to other necessary services;
  7. If you revoke your authorization, all information about you already in the Idaho HMIS system will remain, but will become invisible to all affiliated service providers as of that date;
  8. You are entitled to a copy of this notice if requested;
  9. You have a right to a printed copy of your data contained in the Idaho HMIS database. You have the right to submit a request to correct your information if the record is inaccurate or incomplete;
  10. You have the right to file a grievance if you believe your privacy rights have been violated.

As your child receives services, their file will be updated. This information will be collected so that the U.S. Department of Housing and Urban Development, U.S. Department of Veteran Affairs, U.S. Department of Health and Human Services, Idaho HMIS, Idaho Housing and Finance Association, Continuum of Care, and the affiliated Service Providers can:

  1. Monitor program effectiveness;
  2. Assist in coordinating service delivery systems;
  3. Improve the quality of care and services for homeless individuals and families; and
  4. Prepare internal reports and statistical information with Protected Personal Information
  5. Prepare public reports and statistical information without Protected Personal Information

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Signature Certificate
Document name: Parent Authorization Form
lock iconUnique Document ID: c894e2dad849e3697c792fa55076868eca1b42fc
Timestamp Audit
September 20, 2020 7:59 pm PSTParent Authorization Form Uploaded by Michelle King - lcvyrc@gmail.com IP 134.49.227.156
September 20, 2020 8:39 pm PSTMichelle King - lcvyrc@gmail.com added by Michelle King - lcvyrc@gmail.com as a CC'd Recipient Ip: 96.18.75.208
December 13, 2022 5:13 pm PSTMichelle King - lcvyrc@gmail.com added by Michelle King - lcvyrc@gmail.com as a CC'd Recipient Ip: 134.49.227.156
December 13, 2022 5:15 pm PSTMichelle King - lcvyrc@gmail.com added by Michelle King - lcvyrc@gmail.com as a CC'd Recipient Ip: 134.49.227.156
December 13, 2022 5:31 pm PSTMichelle King - lcvyrc@gmail.com added by Michelle King - lcvyrc@gmail.com as a CC'd Recipient Ip: 134.49.227.156