Confidentiality means that information you share with LYRIC staff (including consultants and volunteers) will not be told to other youth or participants.  However, information will be shared amongst LYRIC staff on a need to know basis to best serve you.  Funders have the right to review client files, but are also bound by the same confidentiality we are.  If LYRIC staff needs to speak to an outside agency or provider you are working with, we will ask that you sign a release of information form giving us permission to do so.  As a participant of LYRIC programming, I also understand that it is my responsibility to maintain the confidentiality of other youth participant’s personal information (i.e. gender identity, sexual orientation, housing status, health information etc.) unless I have expressed permission from them to share this information.  This form is to let you know that all information shared to LYRIC and its staff will be kept CONFIDENTIAL amongst LYRIC staff unless by California State Law we are required to release information because of the below:

1. There is suspected child abuse or neglect, dependent adult or elder abuse or neglect
2. When a participant is in such a mental or emotional condition so as to be dangerous to themselves, others, or another’s property only when such a disclosure is necessary to prevent threatened danger
3. If LYRIC or its staff is compelled by a court pursuant to an order of that court
4. Or when otherwise specifically required by law.

Your Rights

1. It is your choice as to whether or not you sign this document.  Signing it allows you to participate in all LYRIC programming.  Not signing it will allow you to participate in dances and public events only. 
2. It is your right to cancel this consent at any time by informing the LYRIC Program Director in writing of your intent to do so. 
3. You have a right to receive a copy of this document.

By signing this document I,                                                                                                         
                              (Please Print Full Legal Name)          (Name Goes By)
hereby authorize LYRIC to release and/or exchange to one another, verbally and/or in writing, relevant information pertaining to me for the purposes of case management and/or verification of information.  I have read, understood and agree to abide by LYRIC’s Community Agreements. 

In addition, I understand that by participating in any of LYRIC’s programming, including case management and/or counseling, I can experience feelings that are painful and uncomfortable while at other times it may feel relieving and encouraging.  I understand that my participation is voluntary and I can stop at any time.

Expiration:  This authorization expires when I turn age 25 or on the following date:                     

Date of Birth:                                     

Participant Signature:                                                                        Date                                       

Staff Signature:                                                                                  Date