Reality Check Registration Form

Parent/Guardian Overview

You and your child(ren) have been provided this information because of their interest in participating in the Reality Check program of Adirondack Health Institute (“AHI”). You and your child(ren) should review all of the information together to learn more about the Reality Check program and to become familiar with the expectations of being a member. To establish as a Reality Check youth participant and have access to all local Reality Check events, all forms must be completed and returned to AHI’s Reality Check staff member.

Youth and their parent or guardian are responsible for reviewing, completing and returning the documents bolded below and contained in this packet:

• Parent/Guardian Overview
• Reality Check Overview
• Skills Developed
• Parent/Guardian Permission Form (Parent/Guardian Signature Required)
• Medical Release Form (Parent/Guardian Signature Required)
• Code of Conduct Form (Parent/Guardian Signature Required)
• Photography/Video Waiver Form (Parent/Guardian Signature Required)
• Schedule of Events

Meetings and Events

Reality Check meetings will be held after school and will be scheduled according to availability of youth. Youth will also attend or host events throughout the year, depending on community calendars in Saratoga, Warren, and Washington counties. Events may include local community events, movie nights, speaking engagements with local elected officials and more. Dates, times and locations of events may change.

Reality Check youth are required to sign-in for all meetings/events using the sign-in sheets provided by Reality Check staff. Reality Check staff will always be present with youth, except for bathroom use. Youth are required to check-in with Reality Check staff before and after bathroom use. All youth must sign-out and indicate plan for transportation post meeting or event (e.g. late bus, parent/guardian pick-up, driving with friend, etc.). When meetings are held after school, youth who are using school provided transportation are responsible for leaving the meeting in time to take the late bus home. Reality Check staff is responsible for ensuring youth are accounted for during the meeting or event.

Medication Administration

AHI Reality Check staff cannot administer medications to youth. If youth need to take medications while at Reality Check events it is their responsibility to do so as prescribed. Medications, prescribed and over the counter, must be in original containers and include the participating Reality Check youth's name, the name of the medication and prescribed dosing instructions clearly identified on the label. Parent/guardian is responsible for updating their child’s medical information as needed.

Attendance, Expectations and Code of Conduct

Attendance and punctuality at scheduled activities is strongly encouraged for all participants. If youth have a scheduling conflict with a meeting or event, proper notice should be given to AHI Reality Check staff. Reality Check youth are always expected to follow the Code of Conduct. As a parent/guardian, you are required to read the Code of Conduct review it with your child, then sign acknowledging that you and your child understand the standards of behavior expected of Reality Check youth.

Reality Check Staff

Merry Rudinger, Reality Check Specialist, is responsible for the day-to-day operations of AHI Reality Check Program Saratoga, Warren, and Washington counties. If you have any questions or concerns, please contact her at:

• Work Phone: 518-480-0111 ext. 422
• Work Cell Phone: 518-769-0480
• Email: [email protected]

Reality Check Overview

• Reality Check is a strong component of the New York State Department of Health Bureau of Tobacco Control (NYSDOH BTC).
• The Adirondack Health Institute (AHI) is the agency that operates Reality Check in Saratoga, Warren, and Washington counties under the auspices of the NYSDOH BTC.
• Reality Check is for youth ages 13 through 18 and is led by youth with support from adults.
• Reality Check is represented in all regions of New York State with 22 chapters.
• Reality Check is a youth-led action movement with the main goal of exposing the advertising and marketing practices of the tobacco industry.
• Reality Check is NOT against smokers!
• We focus our effort on preventing youth from smoking and using other tobacco products by sharing with them the truth that is known about the tobacco industry and their marketing.

Youth in Reality Check lead the fight against Big Tobacco by making REAL changes that will impact future generations!

Skills Developed

Youth in Reality Check Learn:

• Public speaking skills;
• Communication skills;
• Advocacy skills through working with local, state and federal elected officials;
• Media skills in working with the newspapers, news stations, radio and other forms of media;
• About corporate tobacco, from their history to the present;
• About advertising and marketing, and how media impacts people's beliefs, attitudes and behaviors;
• Skills in problem solving;
• How to plan events, activities, and initiatives;
• Creative ways to advocate for a cause; and
• How to mobilize others to take action!

Youth in Reality Check will Gain:

• A greater understanding of community change;
• Self-confidence and self-awareness;
• Awareness of the power of youth voice;
• Great opportunities that will build towards the future;
• Experience to put on resumes, scholarship applications, job applications, college applications, etc.;
• Community exposure, recognition and community service hours; and
• Opportunities to travel.

Youth involved in Reality Check have a Choice:

• We believe family and school is a priority and we know that schedules are busy;
• Your involvement during events and presentations is according to your strengths and how comfortable you are with what you're doing;
• You choose how involved you want to be in Reality Check; and
• You do not have to come to every meeting, event, or activity.

Parent/Guardian Reality Check Permission Form

PARENT/GUARDIAN INFORMATION

REALITY CHECK YOUTH INFORMATION

Contest to Transport:

By signing below, I agree to ensure transport of my child to and from all AHI sponsored Reality Check activities and events. AHI Reality Check staff cannot transport youth to and from Reality Check sponsored activities and events.

Reality Check youth are required to sign-in for all meetings and events using the sign-in sheets provided. Reality Check staff is responsible for ensuring youth are accounted for during the meeting or event. Reality Check staff will always remain present with youth except for bathroom use. All youth must sign out and indicate plan for transportation post meeting or event (e.g. late bus, parent/guardian pick-up, driving with friend, etc.).

When meetings are held after school, youth who are using school provided transportation are responsible for leaving the meeting in time to take the late bus home.

I the undersigned have legal custody of the minor listed above and give consent for him/her to attend Reality Check activities and events. This consent includes permission for the minor listed above to assist in the development and distribution of materials (e.g. letters to the editor, presentations) to educate members of their community, organizational and legislative decision makers on the deceptive marketing tactics of big tobacco companies. My signature below indicates that I have read and understand the Reality Check Permission Form. I understand that there are inherent risks involved in any event, and I hereby release Adirondack Health Institute, its employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during my child's involvement.

Medical Release Form

Parent/guardian is responsible for ensuring medical and emergency contact information remains current by communicating any changes to AHI Reality Check staff immediately.

EMERGENCY INFORMATION

MEDICAL INFORMATION

While Reality Check staff cannot administer medications, a list of medications is required in the event of an emergency. This list of medications will be kept confidential and will only be shared with medical providers, if necessary. Please list all medications, that your child is currently taking:

I am the parent or legal guardian for the above-named participant and give my permission for him/her to attend activities sponsored by Reality Check. I hereby certify that the information provided is correct.

In the case of a medical emergency, every effort will be made to contact the parent or guardian first. If Reality Check staff are unable to reach parent/guardian, they will notify the emergency contacts listed above. In the event those persons cannot be reached, or time does not permit, I hereby give permission to a licensed physician or other licensed medical provider, to provide proper treatment, including but not limited to hospitalization, injection, anesthesia and/or surgery for the above-named Reality Check Youth. On behalf of myself and my child /minor, I/we hereby RELEASE, WAIVE and FOREVER DISCHARGE Adirondack Health Institute and its officers, directors, employees, parents and subsidiaries, agents, from any and all claims, liabilities, causes of actions, damages, demands, judgments, executions, liens and costs whatsoever, in law or equity, including, without limitation, liability for death or bodily injuries to any person or damage to any property resulting from any (1) claims made against medical providers of emergency services (who are not employed by Adirondack Health Institute) under this authorization, or (2) against Adirondack Health Institute for obtaining medical emergency services for said participant pursuant to this authorization.

CODE OF CONDUCT

The following Code of Conduct is expected and will be enforced at every AHI Reality Check meeting or event. All participants and their parent or guardian must sign this document before youth can participate in events and/or meetings.

• All participants agree to listen and follow the directions of Reality Check staff.
• The possession and/or use of weapons, alcoholic beverages, tobacco products, and illegal drugs is prohibited.
• Any sexual contact is prohibited.
• Any behavior that violates the laws of the United States or the State of New York or any local ordinance is prohibited.
• Stealing will not be tolerated.
• Participants will treat others with respect regardless of race, economic status, gender, sexual orientation, or ability.
• Any inappropriate or disruptive behavior, including bullying, cyber-bullying, intimidation or physical hazing in any form, will not be tolerated.
• Any threats made towards another person must be reported to Reality Check staff immediately.
• All participants are to show respect for the property of others and the facility in which events/meetings are held.
• All participants are to remain on site for the duration of meetings.
• Attendance and punctuality of scheduled activities is strongly encouraged for all participants.

I have read the above Code of Conduct and reviewed it with my parent/guardian. We understand that if I have violated the Code of Conduct my parent/guardian will be notified to pick me up or provide transportation home (at their expense) and I will no longer be able to participate or attend AHI sponsored Reality Check events. The responsibility for making this determination is vested in AHI Reality Check staff.

Publication/Web Site/Photo/Video/Interview Release and Authorization Form

grant Adirondack Health Institute (AHI), its employees and agents, and those acting with AHI permission, to include and identify me or my child in any publication, photograph and audio or visual recordings of any kind and in whatever medium it may use for educational, publicity, and/or fundraising purposes. If I or my child was interviewed by staff from AHI or any affiliate programs, I also give permission to use my name, my story, and any of my direct quotes for education, publicity and/or fund-raising purposes in any medium. I understand and agree that AHI retains all rights to the photographs, moving images, sound recordings, and other media, and that I will not be compensated for any AHI use of same. I hereby waive any right I may have to inspect or approve media that contains my name, image, sound recordings, story, and/or biographical data.

I understand and acknowledge that AHI and its affiliate programs will rely on this Release and Authorization, and I hereby agree not to assert any claim of any nature against AHI, its employees and agents, and/or affiliate programs relating to the exercise of the permissions granted by this Release and Authorization. This Release and Authorization will be in effect for a five-year period from the date listed below, but I understand and agree the materials developed during this period may be utilized indefinitely. I am signing this Release and Authorization voluntarily and understand that provision of services to me by AHI and/or its affiliate programs is not conditioned on whether I sign it. I also understand that I may revoke this Release and Authorization at any time, in writing, but that a revocation will not impact any use or disclosure made prior to the date the revocation is received.