The Plainfield Youth Assistance Program is a voluntary intervention program that utilizes community resources in a holistic, wraparound process to stabilize youth who are considered at risk by statute in the State of Indiana. PYAP
strives to enrich the lives of youth, ages 3 – 17 years, and their families who have experienced complex circumstances
by providing the resources for successful growth and development. All data and personal information from these forms is confidential and will be protected by the Plainfield Youth Assistance Program. I/We, understand that our participation in the Parent(s)/Legal Guardian Plainfield Youth Assistance Program with our child, , is voluntary and in Participating Youth signing these documents, we hereby commit to fully participate in the opportunities provided by PYAP. As such, I/We understand that we will have an Early Intervention Advocate working with us throughout the program and together we will develop a plan in the best interest of our son/daughter and our family and we will follow through with that plan. If at any time, we are uncomfortable with our experiences or have questions about our plan, we will direct those concerns to our Advocate immediately to jointly develop solutions.
*In cases of separate living situations, separation, or divorce, or grandparents with custody, forms can be signed by a parent/grandparent with legal custody or by the legal guardian. In cases of Joint Custody, either parent can sign.
Legal documentation may be required to verify legal consent
Informed Consent: As a parent(s)/legal guardian of a child, youth or adolescent and family participating in the
Plainfield Youth Assistance Program, we hereby inform you that your child and/or your family (all members) may
participate in experiences that involve risk when engaged with some collaborating agencies and organizations.
Release from Liability: Further, as parent(s)/legal guardian of the family, we agree to the following conditions:
• My/Our child(ren) participating in the Plainfield Youth Assistance Program is/are between the ages of three
(3) and seventeen (17) years of age.
• No family member shall be under the influence of influence of alcohol or illegal substances at any PYAP facility, at any facility of a collaborating agency or organization or in any activity with a mentor or volunteer.
• No member of the family shall have any weapon on his/her person during any meeting or activity of the
Plainfield Youth Assistance Program or a collateral resource agency or organization.
• No member of our family has an immuno-compromised condition or infectious disease.
• We agree that any physical condition (including pregnancy) or disability that may endanger the family member or others during participation in activities shall be reported to the Program Director or Early Intervention
Advocate at Intake (first meeting).
Further, should it be necessary that my/our child must be transported by a Plainfield Youth Assistance Program
Volunteer, we waive all claims as defined below.
Fully informed of these conditions and risks, I/We, the parent(s)/legal guardian of legally bound for myself, my heirs and assigns, executors and administrators, do hereby forever release and hold harmless all Staff, Mentors, Volunteers and Officers and Members of the Plainfield Youth Assistance Program Board of Directors from any and all liability, and waive any or all claims for injury, loss or damage caused in whole or in part by as a result of my youth’s and all family members’ participation in the Plainfield Youth Assistance Program, Inc.
Assumption of Risk: I assume all risks, known and unknown, foreseeable and unforeseeable, in any way connected
with my/our family’s participation in the Plainfield Youth Assistance Program any/all collaborating agencies and
organizations. I/We accept personal responsibility for any liability, injury, including death, loss or damage in any way
connected with my child’s participation in the Plainfield Youth Assistance Program and all collaborative agencies and organizations to which our family may be referred and with which we may participate.
The undersigned hereby acknowledges that s/he has read the Informed Consent, Release from Liability, Waiver,
Assumption of Risk form in its entirety, that s/he fully understands the terms of this release and has signed this
release voluntarily and with full knowledge of the effects thereof.