Authorization for Treatment of Emergency Care: 

I hereby give permission to the medical personnel selected by DuPage County Area Project (DuCAP) to transport myself/child listed/registered to a medical facility for treatment. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by DuCAP personnel to secure and administer treatment, including hospitalization, for myself/child or children listed/registered. I release, waive, discharge and covenant not to sue DuCAP, its departments, their respective administrators, directors, agents, coaches, and other employees of the organization, other participants, sponsoring agencies, sponsors, advertisers and if applicable, owners and leasers of premises used to conduct the event, all of which are hereinafter referred to as “releases”, from any and all liability to the participant, his or her heirs and next of kin for any and all claims, demands, medical bills, losses or damages on account of injury, including death or damage to property, caused or alleged to be caused in whole or in part by the negligence of the releases or otherwise.

Communicable Diseases (Including COVID-19): 

In consideration of me, my child/children being allowed to participate on behalf of DuPage County Area Project (DuCAP) and related events and activities, the undersigned acknowledges, appreciates, and agrees that:

  1. Participation includes possible exposure to and illness from infectious diseases including but not limited to MRSA, influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; and,
  2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,
  3. I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe and any unusual or significant hazard during my presence or participation of myself or my child, I will remove myself and/or my child from participation and bring such to the attention of the nearest official immediately; and,
  4. I, for myself and my child on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS DuPage County Area Project (DuCAP), their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“RELEASEES”), WITH RESPECT TO ANY AND ALL ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

Physical Activity:

I understand that DuCAP includes physical sports and recreational activities. Participants with a diagnosis of asthma may keep and use an inhaler during a DuPage County Area Project (DuCAP) Program if a doctor’s note is on file with the DuCAP Central Office. The inhaler must be used in lead staff’s presence.

Photography Release:

I authorize the Illinois Department of Human services, any Affiliate or Sponsor/Partner of DuPage County Area Project (DuCAP), and the local DuCAP Program operators to photograph myself/child/children listed/registered for means of publication purposes. Photos might be used in various brochures and publications describing and promoting the program in a positive way. The photos will not be used in any illegal misrepresentation of my child/children listed / registered. There will be no compensation for any images used.

Outcome Measurement Consent:

I give my permission to the Illinois Department of Human Services, its designees and DuPage County Area Project (DuCAP) to collect and record data on myself/child/children listed/registered. The data may include, but is not restricted to the following:

  • Surveys and/or interviews about his/her knowledge, attitudes, skills, and behaviors in regards to risk-taking behaviors and habits, education and educational resources, positive relationships, career choices,connection to community and overall satisfaction with the DuCAP Program.
  • Academic and school department data from report cards and other school reports. These will be collected each quarter during the school year.

I understand that the purpose of these surveys and interviews is to document the impact of the DuCAP Program on its participants and to identify areas for improvement. I also understand that this information will remain private and that only the site director and assigned research assistants will be able to view this information.