CREATIVE SUPPORT ALTERNATIVES - San Diego State University
Take Charge!
3590 Camino del Rio N 121
SAN DIEGO, CA 92108
Take Charge Release Form
Focus Person & Family Consent
In consideration of my interest in furthering the educational purposes of San Diego State University, Interwork Institute, and Creative Support Alternatives, I hereby consent to any recording of myself on videotape, film, audio tape, paper, digital medium, or otherwise, by said university, its agents, servants, or employees. I authorize the use of such recordings for any proper and legitimate educational or commercial purposes by the university, either on or off campus.
Further, I consent to have San Diego State University students, participating in the Take Charge! Grant, and/or focus-persons, interested in having a person-driven plan performed with them, participate in my person-driven planning process by attending my meeting in an observation role.
I understand that information obtained through the person-driven plans will be shared with the grant funder, the State Council on Developmental Disabilities. In addition, this information may be shared with other transition-aged adults with developmental disabilities while the grant project informs other transition-aged adults with developmental disabilities about the importance of using person-driven planning to aid the transition process.
I acknowledge your ownership of the program and further agree that you may use my name, likeness and biography for the purpose of promoting the program. I warrant and represent that all material furnished by me is my own or for which I have full authority for such purposes.
Signature: Date:
Print name:
Street Address:
City, State, Zip:
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