       IDesILaytags    E 1jra0824Millie BrombacherDSHSjra0824.itp                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              ;  {                                                                                                                                                                                                                                            t                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          4   j   D                     I         c                                                                                                                     &    ,    2    8    >    D    J    P    V    \    b    h    n    t    z                            6     `         Submit                        6       y9gb a                            6         y9                                  6    $                                          6  4  *        35140800190180187                j  H   "               @                 X           
          
 9           @@                        @@                     @@              @@                       @    @@             .       .   T 8T      T ݲ9      0    /  _T      0    9        /  5	8 T .     	    l T / | L 		           	  T    	   "T / 'T 0    /  T LA .    /  T .    .  \A 	                A C 	  
                   . C   A .           @@ H                                       
                                @@                X           
          
 T8 T            @@ @                                                                  N    6  8                                                              3`                                       ##p                                   1&@  XX     jdV      XX         d            '               t ] ?           d        p  H        
    <     p    ( n    1 o    M j     d      i    
   W	YouthNameYouthSignatureDateParentSignatureDateElectronicCommunicationName	MediaName                                                                                                                                                                                                                                                                                                                                                                                             
	Signature        Version x  	Data Versx   $	Blue Keys        *Graphicsx   0Header   6	FieldList   <       z    B  zz     m,    z        ,   m        
)  
     m, 
         4     m,  
 `   m, ,     ,         H   H                                   	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    , `   m,     Z   q    : H >9 23Z 7,⮭H    JN ]   :H  }  ,g   I<; Y $u 7L+H}  v    ^ < |Q  k   A 	  }    9 H  ] ' 3 , H r@Y   :H  
  ,S  i /  :E     {  ljYT            A H   y X  , .H S  _  :H    ,V  c "}} :G N  p 
    i ,       I H     l , .H ֡rG O  :H    ,V  d !罹xQ :H i<S  w 
{Z  q    Q2  A   s  v  H G     V , H  @]  :H    ,V  d w1  :H 5u    {      Z   h  j!  H;  X 	  , 	H 
     :H    ,V  d \  0 :H m   tF N 0      m   a  a+  H: 4> Y    : + 	G  I     :H    ,V  d x  ht 9H   -   W S Q    < b  u   W  V2  J:  c l_  睦 - .D  M% |Ow  6B  e:'P  d $ N- ); 	k5 8A m   E' P Q7I      X+  c  M  K;  V:     U 4E =<	/v N1f f` 		P3r] 7{ 7` 08Q AS./    S  P  @ B E  W<  g rU :>  4A 3Dּmכ yڃ Xk i]  fڛ 	) % 3 ?[   (6  <   )  A )  8  /N? 1. 	   6O= N! 
  FI	 	 )MR1 ,OC  
    6N4 &PJ 
9RC  <  ~ .  J }  l     8 uI ޝ/ +K yìT jN 
dw     
 S   `, ,     ,         H   H                                   	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    , S   `,   B  ~=  Y Q  <  ! : V   o   D 	  1 h 3  w, : V      G 4   ~ *  k6 : W  i       s  u ] 	    c= : S C> ?S =>:
G D;::<D %`M (_Y ]S bM  {      W G : H  i  8  pH  {V *%    | !    "  N P : H   MO Z  
r
 UH 7 KV 	/& *  x  m I   , A Z : H    Pm - D 7H  V!  +V l	 J   w 	   7 9 c : H   Sq 6e + H :H    ,V  4 P  r  J  {7 @ - k : H 9/ s e- , H :H    ,V        x  g d  I " r : H  | o , H .zE 3{C :H  ~  ,S Ls  vS ;p0
	  < [+ vc E~i   B  V   T   } : H   W۲, , H &t	    :H  DH)R|> B U 2fE43݀Iyо "8  2A  '!   ? @   _    : H   / 8L@8=K5 ,H _  y  :H S
!$  ʄ+ lV>O2 9@ UL V!o-      /   h    : H  h ,   ,+H  -   eX  :H o('8 68<  ( PIWP  .6   G  (? 7Y *   
 F   S, ,     ,         H   H                                   	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    , F   S,   L ^  +  , d  NB , 'F` d    9b    ( q  a  ~  p d ZW   d 	+z Il q ?G    > r   !  , e % i , 'dYωnB d  
 W    ( q  c 䊉vM   q d eY   d Q Gp q  #H     f"  T   , _   ,  d  \ U     q  c    q d ]d  d r!   Gd q H           , V  , 	@j  d  g _     q  c    q c Fv   d 8 w   IGu: q P )H      G    + V   + 	
  Q d  G _ &d     q  c    q e "  v  c F B   VX q :F 4J    07     4 V  h" +  7> !E-  d}	6 [_   0DM   	l  c &Mk/ z  q 55  ?.  ` Һ +	 aS   n	( k 4YO      yJ  [ \  ; V  @ K ~. 
 d0  	"Ek  4Y
t@ e . tq  V& Kz* 
_;  ?e  _
ܡy4	AQ   pG    Y l  : V  n 
=w /A  dT A}{z  5-=ڿ T_ _ ` a0 { r  gL N <b۳}6S   G    e n   : V   
	 0H9 d:E! <A  

 H+ 			
 	 'H@  	 	  ,H GJ 
	 )FI* 6J6 $H; 
 <=  	
 ? -   p d  
 : V  w d   >  e
   z Z   : V  J< c   >   %   R   : V & ` `   B   ~>   G   : V 
  ]5     
 9   F, ,     ,         H   H                                   	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    , 9   F,   H 
  C  r     r   f:    e 7    ~     k   DJ:9:FKIH9  gR , P q 4M      '  c  s%       W J    t ]
   e  .  d  N I S,1i G 
iy hWJr 	 K W   q  V   S  9  d % q - 8    p U L   u E'}  N  C  d 	  +  T 7  r Z  < ,   `  C  v K ! d  , 	s  k e  %l     7  j U , d  
 , h 1M S [r h|! 	; 'm 
 xZ  N: z\	  qq ] hI _  >r# 7Y #/ ow    8& b .  a \ , d  X? , I  t Es!E #CG Q~*EN>o.fF V) 1e   H5 O1 \f/ 3 w #`x >S    _ a  ~%  V f , d   , 2 X 6   \N     
XA  d  y( & pX  Wq  L     q   I p , d   , [+ ' v*v@eR [X pG9  e=Y@ĞQ   _M摎( 7*:  Z  |x  )q  yB     P||}xX K @ x , d   , -+   DT a2  r ,=  ?e  9Y  ( 3   t   }-   ^ s  +  \ l)   s;0  w q  <W  TV    gv ur [ 9DBAM 5  , d  s , 4u>f d  # d    ( n  o  ~	  x c Gb   d `   V[n  ,/ q 	4N      
 ,   9, ,     ,         H   H                                   	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    , ,   9,    M( 7   v { V 	QQ. q7( :& :	 ] z  ˎ B H 
d Û  ;    P` W ~ =YL K \   P( 
.  s  ^ c 	Ï  &I [ 
] 
U e    U b ] W (9 ن  } ` [ ȶ  ~ { *  4 &   ! &    q ? q R  )3 2    Y , '< ]   R ՗ V +7  ǹ   X #B  6 
2    Т z   n a  U    ? Óg k n , D T !蠗 _ ʪ W I qכ U ē= D ŗ$    By	 $   U    H  =- I}5P v> G @ 	@ %; !9 ;Iz HH 	ZS !? 2 DJ /P .{QQ 	EP v{  K    E I $  C   D 9 B  K     0	  . e  *
 =  < 	   W  :       s h  ;   ?  C        :   7  L          ;   D  V      WE   :      b    { - m   :  h 1   j    q       
    ,, ,     ,         H   H                                   	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    ,    ,,     1 . l      tS   / yxu\. Nggfijjgz+G   3  % 88787#(gZz3   I ,  Xn   
   %6  O  2P 0 3  4N  . o ; (8  Q R 0D  P  [  {s F 1  [  ` ]   * I     V  K % f 0 %Z 
Ӆ   4'    	   l   2  g x  ҄ 
      b   d  0 qضQ D0 F J Zu6 s x 0o r iu zf	 g ,F n r \ 
.    x    % xR  < < tCۓ ̛ 
Me' "G z< eEX: ڿQx5 f8 JS ~> / ?ۦ   {	    1 f 
$	PW 
   ?    
f (#     X "O  މ ! ;% 2 < m) ]	 L +       XI 	an  *!  9CB@ 
q BB =ތ f G X "@ R  c Q    g y B e *q ( ,  p15Ҟ   "{
  C  ^ ?, 	@ 9 l9 H  8) O     r ͌   3 q    W Q r ܼW   
    , ,     ,         H   H                                   	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    ,    ,   &  K    P    1   ( ) N      E   '  ! C q  k  f U   ) /6 #  \  X V   (  dD 6I  \  X W   '  0  i  t  y P   ( 
 d<    /   + 
  {>  v   1 b )           M    y  u m	      k  3 S&         M     
    , ,     ,         H   H                                   	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    ,    ,     {    % * 
>M   &  	;1o m 4ޒA   $ #  *      @#  D #*     m   | p 7!      O ;      %  -    _   *     w>+3Z
   )   
   r  G   '      ~  k    )    !   L    (  uB U }  |(  \     
     , ,     ,         H   H                                   	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    ,     ,    DqүR     NN    	    *!                   0    I            
  /  /        @@                 X           
         
           @@                        @@                     @@              @@                       @    @@              ` 4  d      4  ` d T 8T      T ` wd     0    \/ | _T      0    nw	      \/  5u T      u    T \/   vu         v  T    u   "T \/ 'T     \/  T LA     \/ ( T     </ D \A u  D  1          T  A 8          1             8  A            @@ H                                       
                                @@                X           
          
D             @@ @                                        
                                  @@                 X           
          
(                 @@ @                                      
                                @@                X           
          
                           H    N   T                     D  N   "                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               x     
       (          "                        (q,q,q,q,q,q,_ddq,   
                                porpsila  Z   porpsila  `     < E            porpsila  l   porpsila  r                               Arial                                                           Times New Roman                                                               Tit        t                 !        #@              /   , consent to appear, or have my name appear, in           
        m 
N weR        0Pp H                                                      i       ``                Title      	                            pP                YOUTH'S SIGNATURE      	             m  New R S                   !`"$              H   To be completed by Parent/Legal Guardian if participant is under age 18.          
       m 
N weR a  
    #p$#                 I present that I am the parent/legal guardian of the youth who has given the above release.  I agree to the terms of this release and consent to my child's participation.           
        JJ- YB    J   -  B  Y        
 8                 
- YB ,  Arial         
 (? zI present that I am the parent/legal guardian of the youth who has given the above release.  I agree to the terms of this             (K 0release and consent to my child's participation.                 %P( p H                              '0                        j       '@`( `                Title      	                            'P'P                YOUTH'S SIGNATURE      	             m  New R S      &'      ' '        /P/`             S   DSHS 20-XXX (08/2002) AMBER GILLUM - JRA 0821 - PROPOSED FORM - DO NOT PRINT MILLIE                 m N weR                       I,           
        m 
 New R       	p"` H                                                       n       "P                Title      	                            
@"p "                .           
        m 
N weR        `#                  0"p                 Any information about other JRA youth, other youths' families, or victims of an offense is confidential and must not be shared or disclosed.          
        ((    1    (       1           
 8                 
    1 ,  Arial        
 (  *lAny information about other JRA youth, other youths' families, or victims of an offense is confidential and          (  * must not be shared or disclosed.                                  I authorize the use of my name and my voice including any statements that I may make during taping.I understand that my pariticipation is this media activity is voluntary.  I understand that           
        ff  (    f        (        
    1                 
  ( ,  Arial         
 ( dI authorize the use of my name and my voice including any statements that I may make during taping.                   ( [I understand that my pariticipation is this media activity is voluntary.  I understand that                Pp H                                                      o       P`                Title      	                            "@             1   maintains total ownership of the production tape.           
          "?B.     ?  "  .  B        
 8                 
"?B. ,  Arial         
 (4I1maintains total ownership of the production tape.                @              G   I understand that I will not receive compensation for my participation.           
          : Z[        :  [  Z        
 8                 
: Z[ ,  Arial         
 (L GI understand that I will not receive compensation for my participation.                 #                 I agree to release the State of Washington, Department of Social and Health Services, Juvenile Rehabilitation Administration from any liability to any person or organization that occurs as a result of my participation in this project or related media activity. XX (08/2002) AMBER GILLUM - JRA 0821 - PROPOSED FORM - DO NOT PRINT MILLIE                                                      N    Z   3     Submit                              I  f    jra0824166  T 8T  1   T   V}     `  Millie Brombacher    `    V}DSHS      J  I     jra0824.itp T / l <                                 l      XX     jdV      XX         d            '               t ] ?           d                               6  c  r                                      {        O                     "                  _޹_޹_޹_޹_޹_޹__                                 porpsila  Z   porpsila  `     < E            porpsila  l   porpsila  r                                                Times New Roman                                                                               6  ;  ~   this                                               
	Signature        Version x  	Data Versx   $	Blue Keys        *Graphicsx   0Header   6	FieldList   <	Form Info        fLayoutProps0}  xDesPathInfoTf  ~       s    T  W                       m,  B        @             @   >JUVENILE REHABILITATION ADMINISTRATION (JRA)YOUTH MEDIA RELEASE      	              ,      
         -  
                 	pp H                                                      d       	p`                NAME OF YOUTH      	                  y B       #@              /   , consent to appear, or have my name appear, in           
         
         P p H                              P                        i       `` `                DATE      	                            p @                SIGNATURE OF PARTICIPANT      	                 q      "               !`"$              H   To be completed by Parent/Legal Guardian if participant is under age 18.          
        
  a  
    #p$#                 I present that I am the parent/legal guardian of the youth who has given the above release.  I agree to the terms of this release and consent to my child's participation.           
        JJ- YB    J   -  B  Y        
                 
- YB ,  Arial         
 (? zI present that I am the parent/legal guardian of the youth who has given the above release.  I agree to the terms of this             (K 0release and consent to my child's participation.                 %P( p H                              '0                        j       '@`( `                DATE      	                            'P'                 SIGNATURE OF PARENT/GUARDIAN      	                       &'      ' '        /P/P                DSHS 20-247 (02/2003)                      ?                      I,           
         
         	p"` H                                                       n       "P             V   NAME OF TELEVISION, RADIO, VIDEO, NEWSPAPER, MAGAZINE, ELECTRONIC COMMUNICATIONS, ETC.      	                           
@"p "                .           
         
         @#                  `"p                 Any information about other JRA youth, other youths' families, or victims of an offense is confidential and must not be shared or disclosed.          
        ((    1    (       1           
                 
    1 ,  Arial        
 (  *lAny information about other JRA youth, other youths' families, or victims of an offense is confidential and          (  * must not be shared or disclosed.                 0p                 I authorize the use of my name and my voice including any statements that I may make during taping.I understand that my participation is this media activity is voluntary.  I understand that           
        ff  1    f        1        
    1                 
  1 ,  Arial         
 ( dI authorize the use of my name and my voice including any statements that I may make during taping.                   (# ZI understand that my participation is this media activity is voluntary.  I understand that                 p H                                                      o        `                NAME OF MEDIA      	                     ?       P"@             1   maintains total ownership of the production tape.           
          +?K.     ?  +  .  K        
                 
+?K. ,  Arial         
 (=I1maintains total ownership of the production tape.                             G   I understand that I will not receive compensation for my participation.           
          C c[        C  [  c        
                 
C c[ ,  Arial         
 (U GI understand that I will not receive compensation for my participation.                0#                 I agree to release the State of Washington, Department of Social and Health Services, Juvenile Rehabilitation Administration from any liability to any person or organization that occurs as a result of my participation in this project or related media activity.           
        _ B       _  B          
C c[                 
_ B ,  Arial         
 (s nI agree to release the State of Washington, Department of Social and Health Services, Juvenile Rehabilitation             ( Administration from any liability to any person or organization that occurs as a result of my participation in this project or            ( related media activity.                #              l   I have read, or have been read this release and indicate my full understanding.  I consent by signing below.           
         
                    
          
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