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2. Community Attention Youth Internship Program Agreement to Participate

   A completed CAYIP application packet consists of three parts: 

   1) The CAYIP Application

   2) The CAYIP Agreement to Participate,

   3) The Youth/Guardian Expectation Form. 

   This is section 2 of 3.

4. Whereas
6. First Name of Youth *
7. Last Name of Youth*
9. a juvenile, born on
11. Date of Birth *
    mm/dd/yyyy
13. has been referred to the Community Attention Youth Internship Program (CAYIP) and
15. First Name of Legal Guardian *
16. Last Name of Legal Guardian *
18. is/are the legal guardians of the youth, the parties involved agree to the following:
20. 1. Parent/Legal Guardian hereby grants permission for the above-named youth to participate in Community Attention's Youth Internship Program.
22. 2.Parent/ Legal Guardian hereby grants permission for the above named youth to participate in program activities at the following business/non-profit/educational or government entity: (hereinafter “Site Participant”).
24. 3.The above-named youth agrees to cooperate with the services and staff of Community Attention as designated by the referring agent, Community Attention staff, the Site Participant staff and/or his/her family.
26. 4.Both the youth and his/her parent/legal guardian acknowledge that they have had the program and the nature of the Site Participant explained to them, including but not limited to the general nature of the work to be performed and what the expectations will be for all parties involved. By agreeing to participate in this program, the youth and his/her guardian acknowledge that they will abide by all the rules of the program and, in consideration of the opportunity to participate in the program, agree to assume any and all risks associated with the program and/or the placement/ assignments of the Site Participant.
28. 5.Parent/Guardian of the youth further grants permission for the youth to be taken on trips, meetings, and/or on recreational activities, and releases the City of Charlottesville/Community Attention and their officers, employees and agents from any liability for injury in connection with such trips, except such liability as may result from negligence on the part of the City of Charlottesville and/or Community Attention.
30. 6.Parent/Guardian hereby agrees to hold harmless and indemnify the City of Charlottesville, Community Attention, the Site Participant and their respective employees, officers and agents, from liability for injury, loss, or damage, including related costs and expenses, arising out of the performance of this agreement, except such liability as may accrue as a result of negligence on the part of City of Charlottesville and/or Community Attention and/or the Site Participant.
32. 7. In an effort to keep participants, staff, and community members safe all program participants are expected to follow the City of Charlottesville policies regarding COVID mitigation. If a youth refuses to comply with these expectations, they may be excused from the program. Please be advised that these mitigation strategies may include but are not limited to masking, proof of vaccination and/or COVID testing.
34. 8. Some CAYIP partners may have additional mitigation practices and policies. If your child is matched and accepts placement at a site, the expectation is that your child would follow the mitigation practices and policies outlined by that site.
36. 9.In the event that the youth/family are not satisfied with the services or program from Community Attention or the Site Participant, they agree to address their concerns with the Program Coordinator and not the Site Participant.
38. 10.I consent and agree to allow my child to be videotaped or photographed during program activities by the Department of Human Services and its partner agencies. The video and photographs may be used for training staff and for marketing and publicity of the program, including social media by DHS or its partner agencies. I specifically consent and allow my child to participate in interviews, recordings, photography and/or videotaping by news media related to their DHS experience. I agree and understand that from time to time, the news media may use their image and words for the purposes of broadcast to the public.
40. 11. I agree to allow information about my child’s internship performance to be exchanged between Community Attention Staff, referring agents, Site Participant supervisors school personnel at (name of school), and other contacts as listed in the application packet.
42. 12. Parents/Guardians are responsible for ensuring the youth has reliable transportation to and from their internship site, which may include coordinating, planning, or providing transportation themselves.
44. 13. In the event that any term, provision or condition of this Agreement, or the application thereof to any person or circumstances, shall be held by a court of competent jurisdiction to be invalid or unenforceable, the remainder of this Agreement, and the application of any term, provision or condition contained herein to any person or circumstances other than those to which it has been held invalid or unenforceable, shall not be affected thereby.
46. 14.This Agreement shall be governed by and construed in accordance with the laws of the Commonwealth of Virginia. All litigation arising out of this Agreement shall be commenced and prosecuted in the federal, state or local court(s) having jurisdiction within the City of Charlottesville, Virginia. This Agreement represents the entire agreement between the parties, and there are no other agreements or understandings between the parties, either verbal or written, which have not been incorporated herein.
48. 15. By signing this agreement, all parties acknowledge that they have read and understand the agreement and understand their mutual responsibilities under the agreement and intend to be bound hereby as evidenced by the signature below.
50. 15. Finally, my signature on this form acknowledges that I was given a copy of this consent for my own records.

    Finally, my signature on this form acknowledges that I was given a copy of this consent for my own records.

52. Youth Signature and Date*
54. Parent/Guardian Signature and Date*
56. Community Attention Representative Signature and Date
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit Submit and Print

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