Diabetes Empowerment Education Program Consent Form

I agree to take part in the Diabetes Empowerment Education Program (DEEP) classes (the “Classes”).

I know the Classes will take place in a group, either in person or over the computer.

To be in the Classes, I agree to all these terms:

1. I know I can choose to go or not go to the Classes.
2. I will not share health information of a person in the Classes.
3. I will not share whom I see, nor what I hear in the Classes with others.
4. I will not use my phone in the Classes to record or take pictures.
5. If the Classes are online, I will not let others see my computer screen or hear what is said during the Classes.
6. I will fill out a test before and after the Classes. The City of Austin will keep and use information from those tests in its records. It will do this confidentially and will follow the laws about how long it keeps that information and how it must protect that information.
7. I understand and agree that the City makes no promises about the Classes and does not guarantee that the Classes will improve my health.
8. WAIVER AND RELEASE: I release the City of Austin, and  its employees, officials andagents, from any and all claims for damage, breach of confidentiality, or injury that I might have as a result of my taking these Classes. I waive all such claims whether by or for me. I agree that this release and waiver will prohibit my heirs, executors, administrators, or assigns from asserting any claim on my behalf. This release and waiver applies to any and all damage, breach of confidentiality, or injury resulting from my taking part in the Classes, whether it involves negligence, gross negligence or misconduct by the City or anyone else. The City of Austin will not be held liable for any financial or other damages resulting from breach of confidentiality committed by members of the group.
9. If any term of this City of Austin DEEP Consent Form is found to be invalid or unenforceable by law, the rest of the terms stay in full force.
10. I am at least eighteen (18) years of age and can read, understand and sign this form. I have read this form, know what it means, and I choose to sign it so I can be in the Classes.

I agree to each of the terms stated above, including the WAIVER AND RELEASE in paragraph 8: