Participant Signature Page
Revised 02/01/2021
Participant Acknowledgement of Receipt
I confirm that I have received the documents below via an enrollment email, read, and understand the following
documents.
• Civil Rights Statement
• Philadelphia Works Grievance Procedure
• Philadelphia Works Privacy & Confidentiality Statement
Waiver and Release
Programs implemented by E
3
and WorkReady partner organizations are managed by Philadelphia Youth Network (PYN). From
time-to-time PYN and these partner organizations create promotional and educational materials about PYN, and E
3
and
WorkReady Philadelphia programs. I hereby give permission to PYN, its employees, affiliates, representatives, contractors,
agents and members of the media to interview, audiotape, photograph, videotape, film, or capture by any other electronic or
other means my image and speech, and, within its absolute discretion, to release, disseminate, or use, in any manner it sees fit
including publications and web pages, the resulting images and testimonials and any other information contained therein for the
purpose of promoting the objectives of PYN, and its programs. I hereby release all actions and claims which I, my family
members, my child, heirs, executors, or administrators may have against the Philadelphia Youth Network, Inc., its employees,
affiliates, representatives, contractors, agents, successors and assigns, arising for any reason whatsoever from the use,
publication, distribution, or republication of the words or images gathered for the purpose described above. I intend this to be a
legally binding agreement.
I DO NOT agree to the terms of “Waiver and Release” statement.
Buckley Amendment
Programs implemented by E
3
and WorkReady partner organizations are designed to provide participants with meaningful
learning experiences, including preparation for the workplace and higher education opportunities, and success in school managed
by Philadelphia Youth Network (PYN). I understand that the Buckley Amendment to the Family Education Rights and Privacy
Act of 1974 guarantees that my or my child’s academic record will not be discussed with or disclosed to any third party without
my written consent. I hereby authorize officials of the School District of Philadelphia to release my/my child’s educational
records (limited to standardized tests, graduation and promotion information, and copies of report cards). This consent will last
until I/my child is no longer enrolled in a PYN-sponsored activity or until I rescind this consent in writing. I understand that this
information will not be provided to any entity other than those indicated above. I understand that a record will be maintained in
my/my child’s file, indicating that the information was provided. I understand that I may acquire a copy of this record, as well as
of any records provided to PYN, from the Philadelphia School District.
I DO NOT agree to the terms of “Buckley Amendment” statement.
Participant Application Certification
I certify that the information provided is true to the best of my knowledge. I am also aware that the information provided is
subject to review and verification (including school records, public benefits, and wage records), that I may have to provide
documents to support this application and authorize Philadelphia Youth Network (PYN) and its agents and program partner
organizations to make inquiries regarding available program services. I am also aware that I am subject to immediate
termination if I am found ineligible after enrollment and may be prosecuted for fraud and/or perjury. I allow release of this
information for verification purposes and understand that it will be used to determine eligibility.
By signing the below, I acknowledge that I have read and agree to the all of the above: Waiver and Release, Buckley
Amendment, and Participation Applications Certification.
____________________________________
_________ ________________________________________ ____________
Participant’s Signature Date Parent Signature (if under 18 years old) Date
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
