Recruit Hippo

Media and Data Release Form

Participant Full Legal Name:

Media Sharing: I, the undersigned, hereby consent to the use of my likeness and words by Southwestern Oregon Workforce Investment Board (SOWIB) and it’s Contractors. The agency has the absolute right and permission to copyright, use, re-use, publish, and republish them for educational programs, publicity, and noncommercial public service announcement purposes. The photographic portraits, pictures, videos, or audio-tapes of me or in which I may be included, in whole or in part of composite or distorted in character or form, may be used without restriction as to changes or alterations, from time to time, in conjunction with my own or a fictitious name, or reproductions thereof; in color or otherwise made through any media for the promotion and educational purposes of these agencies. I understand that the photos, videos, or audiotapes will not be used in a manner that is degrading, libelous, unlawful, profane, obscene, pornographic, or tend to ridicule. I consent to the use of any reproduced matter in conjunction therewith, with the same reservations as above. I hereby waive any right I may have to inspect or approve the finished product or products or advertising copy or printed matter that may be used in connection therewith or the use to which it may be applied. I hereby release, discharge, and agree to hold harmless Southwestern Oregon Workforce Investment Board and it’s Contractors, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said picture, videotape, or audiotape, or in any subsequent processing thereof, as well as any publication.

Data Sharing: By signing below, I hereby authorize the Youth Employment Advisor and the school or program identified below to share information I provide in enrolling and participating in an internship (such as the participant profile, survey data, etc.) SOWIB and it’s Contractors. SOWIB and it’s Contractors will use this information to track regional internship placements and the impact of the Recruit Hippo initiative on regional educational and workforce development outcomes. Personally identifiable information collected by SOWIB will not be shared or disclosed to any other entities not specifically identified in this agreement. I acknowledge that my participation with Recruit Hippo is voluntary, that I may withdraw at any time, and that I will receive no financial compensation from SOWIB or it’s Contractors for participating.

I hereby warrant that I am of full age (18 or over) and have every right to contract in my own name in the above regard. I state further that I have read the above authorization, release, and agreement, and that I am fully familiar with the contents thereof.

Signature:			Date:

Printed Name:

- IF UNDER 18 -

As parent or guardian of the participant named above, I state that I have read the above authorization, release, and agreement, and that I am fully familiar with the contents thereof.

Parent/Guardian Name:

Date:

Southwestern Oregon Workforce Investment Board is an equal opportunity employer/program. Auxiliary aids and services, alternate formats and language services are available to individuals with disabilities and limited English proficiency free of cost upon request. This program funded in whole or in part through the US Department of Labor and/or WIOA.

YOUTH AGREEMENT

When applying for services, there are expectations and responsibilities to which you will have to agree. By signing below, you are indicating the seriousness of your interest in our services.

General Rights

You have the right to:

1. Have all information explained to your satisfaction.

2. Receive prompt attention to problems.

3. Receive copies of any papers that pertain to your participation.

You have the right to be free from discrimination on the basis of sex, race, color, creed, religion, national origin, disability, sexual orientation, gender identity or expression, or any other status protected by law in your placement. To report instances of discrimination, you may contact SOWIB, Rena Langston Program Manager 541-900-5558 / rlangston@sowib.org or your School to Career Coordinator at your school site. I have read and understand.

Initial

General Responsibilities

It is your responsibility to:

1. Cooperate with your Youth Employment Advisor(YEA).

2. Ensure your YEA receives all necessary paperwork in a timely manner.

3. Inform your YEA of any changes,such as address, phone number, name, etc. when they occurr.

4. Immediately notify your YEA of any changes or problems in your work, training, or circumstances that may affect it.

5. Be at your internship or summer job site on time, be appropriately dressed and groomed, and be ready to learn.

6. If for any reason you are unable to attend your scheduled activity, please notify your YEA.

7. Participate and successfully complete agreed upon activities.

8. Maintain monthly contact with your Youth Employment Advisor, via phone, e-mail, letter or in person.

9. Seek all available resources.

10. Obtain employment upon completion of your internship if you choose to doso.

11. Present accurate information to your Youth Employment Advisor. Giving fraudulent information may lead to termination from the internship.

I hereby agree with the Youth Agreement described above and will do my best to complete everything indicated. I also realize that by signing this letter, it does not obligate SOWIB for the funding of my services


Participant Signature		Date


Parent/Guardian Name (IF UNDER 18)		Date


Staff Signature		Date