SUMMER PROGRAM ELIGIBILITY FORMS

PLEASE SELECT ONE*

The State of South Dakota, Department of Human Services created this media.The State of South Dakota, Department of Human Services received this media from me.
I hereby grant the State of South Dakota’s Department of Human Services (hereafter “the Department”),permission and consent to record my image and to use and publish my name, photograph, and/or video of myimage for use in the Department’s videos, printed publications, websites, social media, or any other venue ormedium, and to freely use such information and images as the Department may elect. I understand and agree thatthese recordings of my image are the exclusive property of the Department.
I hereby grant the State of South Dakota’s Department of Human Services (hereafter “the Department”), permission and consent to use and publish my name, and the photograph, and/or video of my image which I have submitted for use in the Department’s videos, printed publications, websites, social media, or any other venue or medium, and to freely use such information and images as the Department may elect. I understand that ownership of this media is retained by me, but I am allowing the Department to use this media at no charge. Brief description of image(s) submitted to the Department:
Brief description of image(s) submitted to the Department
I hereby hold harmless and indemnify the State of South Dakota, the Department, its officers, agents and employees, from and against any and all actions, suits, damages and liability or other proceedings which may arise as the result of or in connection to the use of said information, photographs, videos, or images; and waive any claims which may arise. I have read and understood the provisions of this agreement, and voluntarily agree to all the terms herein.
Print Name*
Date*

MonthDayYear
Date
Participant Signature*

Clear
Telephone Number*
Parent/Guardian Name (if individual is under the age of 18 or is under Guardianship):
Date*

MonthDayYear
Date
Print Name*
Parent/Guardian Signature*

Clear
Telephone Number*

Media Release Form
Address: 2885 Dickson Drive, PO Box 218 Sturgis SD, 57785 Phone: (605) 347-4467

I hereby grant to BHSSC – Black Hills Special Services Cooperative (hereafter referred to as BHSSC) permission and consent to publish my name and photograph (and by video photography) my image for use in BHSSC’s videos, printed publications, websites, and social media, and to freely use such images in the exhibition, advertising, editorial use and publicizing thereof as BHSSC, its assigns, successors and licensees may elect. I acknowledge that since my participation in videos, print publications, websites, and social media produced by BHSSC is voluntary, I will receive no financial compensation. I further agree that my participation in any videos, print publications, websites, and social media produced by BHSSC confers upon me no rights of ownership whatsoever. I also release BHSSC, its contractors, and its employees from any and all liability for any claims by me or any third party in connection with my participation.

Parent/Guardian Signature (if subject is under the age of 18):
Print Name*
Type Name
Date*

MonthDayYear
Date
Participant Signature*

Clear
Parent/Guardian Signature (if subject is under the age of 18):*

Clear
Contact Info.*
Preferred method of contact e.g. email and/or phone number

BLACK HILLS SPECIAL SERVICES COOPERATIVE VOUCHER FOR PAYMENT
Participant Name*
Participant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Invoice No.
Invoice Date

MonthDayYear
Date
Code
Description
Amount
Total Voucher Amount
I declare and affirm under the penalties of perjury that this claim has been examined by me, and to the best of my knowledge and belief, is in all things true and correct.
Participant Signature and Date
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

POTENTIALLY ELIGIBLE DATA FORM

Student Demographics

Qualification for Potentially Eligible (PE) Status

Description of Pre-Employment Transition Services (Pre-ETS) Provided

Media Release Form

BLACK HILLS SPECIAL SERVICES COOPERATIVE VOUCHER FOR PAYMENT

Participant Signature and Date