ANNUAL CONSENTS TO PARTICIPATE


  

Required of all participants annually. Release expires one year from date signed, unless revoked in writing by the participant prior to that date.

 

_____________________________________________   ____________________________________________

Participant’s Name (please print)                                       Emergency Contact or Guardian (please print)

 

(  __    )________________  ( ___     )________________ ____________________________________

Contact Phone Number               Contact Fax Number                   Contact E-mail

 

 

Please “X” One

 

I Approve

I Do Not Approve

Participation in Services:  I understand that the services may include both in-house and community-based training experiences. I further authorize MMI to release to the funding source or entity purchasing these services any information or records relevant to participation and progress in the program and hereby release MMI from liability on account of having furnished such information. This consent also indicates the participant’s agreement to follow all MMI rules as outlined in the Consumer Handbook.

 

 

 

Emergency Treatment:  It is the policy of MMI to notify emergency contacts or guardians prior to procuring medical treatment. It is understood that this consent will be used only when needed for emergency medical needs and when the contact or guardian is unavailable. I hereby grant permission to MMI and its representatives or employees to obtain emergency medical treatment when needed for the participant listed above.

 

 

 

Tours, Photographs, Video/Audio Taping:  From time to time, MMI may develop training opportunities to educate others and promote opportunities for people with barriers to work or independence. To ensure the right to privacy and confidentiality, MMI requires prior approval of the person served (or his/her guardian, if applicable) to be present when tours are being conducted or when the program or participant is being photographed, videotaped, or audio taped. Prior to members of the general public touring the facility, an announcement will be made. At this time, the participant referenced above will have the option of participating in ongoing activities or may go to a designated area that is excluded from the tour. Despite this release, any person may refuse to participate in photographing or video/audio taping at the time of the event.  You may consent to any or all of the following activities:

 

 

 

1.       I consent to participate in the usual program activities during tours.

 

1.

 

1.

2.       I consent to photographing or video/audio taping for purposes related to the rehabilitation services purchased for this participant.

 

2.

 

2.

3.       I consent to photographing or video/audio taping for purposes of training and orientation of staff and program participants.

 

3.

 

3.

4.       I consent to photographing or video/audio taping for purposes of public relations, promotional materials, and informational purposes.

 

4.

 

4.

If any section above is not marked (left blank), approval will be assumed.

 _____________________________________________________                          _____/_____/_____

Signature of Participant or Guardian                                                                                 Date

 

_____________________________________________________                          _____/_____/_____

Witness                                                                                                                          Date


 

 


  

CONSENT FOR PERSONAL CARE

(Required of all participants annually who may need opposite gender personal care assistance.)

(Release expires one year from date signed, unless revoked in writing by the participant prior to that date.)

 

To assure the individual’s right to privacy, MMI will make reasonable efforts to provide staff of the same gender for personal care and restroom assistance. However, due to staffing constraints, this may not always be possible. This consent allows for opposite gender assistance to assure prompt response to assistance needs.

 Please print:

 

______________________________________________________  ____/_____/_____

Participant’s Name                                                                                       Date of Birth

 Please check (a) one box:

 

Statement

I Approve

I Do Not Approve

I hereby give consent for MMI staff or volunteers of the opposite gender to provide personal care and restroom assistance as necessary to the participant listed above. I understand that this consent is voluntary and that I may revoke this consent in writing at any time.

 

 

 If any section above is not marked (left blank), approval will be assumed.

 Signed:

  

______________________________________________________  ____/_____/_____

Participant or Guardian                                                                                    Date

 

 

______________________________________________________  ____/_____/_____

Witness                                                                                                          Date