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The following Consent Agreement outlines several types of services or activities that may be made available to you, your child, or your family member by Wood County Society (WCS or “agency”). Please read each statement carefully and be certain that you understand the statements before consenting to participate in services provided by our agency. The bottom of the page includes designated space to include an explanation for which you do not provide consent. Consent is not time limited. If you wish to withdraw your consent after it has been given, please contact Brandon Gress, Executive Director at the address below. Brandon Gress, M.A. Executive Director Wood County Society P.O. Box 1325 Parkersburg, WV 26102 304-428-4280 - Ext 1 1. I understand the purpose of WCS is to broaden opportunities for all individuals with disabilities throughout the Mid-Ohio Valley Region. These services may include but are not limited to receiving library materials, training, family coaching, direct services, and taking part in one of the 19 programs offered. a. I understand that there is no guaranteed time by which I, my child, or family member will be selected for services. b. I understand I must be willing to make a commitment to work with others who support my child or family member. 2. I understand I am free to withdraw as a registered consumer at any time without penalty to me, my child, or my family member. 3. I consent to allowing staff of WCS to observe me, my child or my family member should such an observation be deemed necessary by both parties. 4. I understand that WCS is not responsible for any fees or charges that result from additional assessments, i.e., medical exams, even if these evaluations are recommended by WCS. 5. Participation in any service may involve some risk, including the loss of confidentiality. I understand that WCS will take all reasonable precautions to ensure confidentiality as prescribed by law. 6. The direct care service programs are based on a body of literature which supports the notion that caregivers are vital components for the positive prognosis for their children/family member. 7. Wood County Society staff are mandated to report to Child or Adult Protective Services should they obtain knowledge of or suspect abuse or neglect. 8. You are free to question the use of any procedure, and you may request that a specific procedure(s) not be used. Any procedure in question will be terminated upon your request even after the procedure has started. Your request for termination of a specific procedure(s) will not affect you or your child/family member’s continued participation in the program. 9. You are free to withdraw your consent at any time without penalty to you or your child/family member. You will still be eligible for other services and programs offered by WCS. 10. As with any service program, there is a chance that the program will not produce any significant changes for your child or family member. 11. In the event of injury or illness as a result of participating in this program, WCS shall not be held responsible. The cost of medical care will be your responsibility. 12. The time commitment for attending meetings, trainings, and implementing procedures at home may be viewed as disruptive to normal family schedules. All efforts to accommodate family schedules will be made. 13. This consent allows WCS to alert school personnel (special education director, principals, teachers and specialists) that we will be providing support to your child or family member and will be inviting them to participate. 14. Any questions or concerns may be directed to: Brandon Gress, M.A. Executive Director Wood County Society P.O. Box 1325 Parkersburg, WV 26102 304-428-4280 - Ext 1 I consent to allow WCS to create digital audio or video recordings or take photographs of me and/or my child or family member with my permission. I understand recordings and/or photographs may be used for training others to work with and understand persons with disabilities, to increase public awareness, be used in scholarly or training activities as well as the Wood County Society Telethon on-air, social media pages, publication, brochures, newspapers, commercials, and bulletin boards. I understand my name and the names of those in my family will be kept confidential. I understand that I have no authority to amend the content of visual or auditory media. Further, I understand that I have no legal right to any financial remuneration from this experience. I understand I will be alerted prior to the use of media in which I, my child, or my family member is involved. I also understand I may revoke this Consent for Media permission at any time during my relationship with WCS. Please select I Agree or I Disagree beside the category for which you provide informed consent. If you wish to withhold consent, or modify your consent in some manner, please explain your intent in the space provided. Consent is not time limited. If you wish to withdraw your consent after it has been given, please contact Brandon Gress, Executive Director. Please note: by providing your consent specific to the program, you are agreeing to participate in these programs, and allow WCS to exchange information with schools or other institutions that serve the client.

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