Dear Parents,
Your son or daughter has been invited to take part in the insert name of program at insert location.
The program will meet on insert meeting days and time , from insert start month to insert end month.
The insert name of program offers the opportunity for young people to:
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Learn about healthy growth and development
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Explore their goals for the future
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Learn how to develop healthy relationships with other young people and adults
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Receive tutoring and homework assistance
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Work on volunteer service projects in Gaston County
The insert name of program utilizes the Wyman Teen Outreach Program curriculum which has been shown to be a positive experience for young people. Many Teen Outreach Program teens have done well in school and avoided risky behaviors.
Insert your organization name insert name of program is funded by Gaston Youth Connected through a grant from the Centers for Disease Control and Prevention. Your child will be asked to complete evaluation surveys, as listed in the box below. Your child’s name will not be used, and all information about your child will be kept private. Your child can choose not to answer any question and will still be able to take part in insert name of program.
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Consent to Participate in Surveys & Data Collection I give my consent for my child to participate in
Wyman surveys. In compliance with Children’s Online Privacy Protection Act (COPPA), Wyman provides the following information to survey participants. Wyman Center, Inc. operates a secure environment to collect and store information from student participants in its Teen Outreach Program®.
Wyman collects the following types of information directly from TOP
® participants through online surveys:
-Opinions about their experience in TOP ®
-Demographics – Zip code, ethnicity, gender, most frequent guardian, parents’ education level
-School records - Grade in school, absences, truancy, suspension, course failure, graduation and schooling plans
-Health information - Pregnancy, parenting, how to prevent pregnancy and sexually transmitted infection
I understand Wyman uses the participants’ responses to improve the Teen Outreach Program ® . I understand that survey and data collection is voluntary and that my child may choose to participate or discontinue participation at any point in the process without risk of losing Wyman’s services. I am also aware Wyman will not require my child to disclose more information than is reasonably necessary to participate in Teen Outreach Program ® as a condition of participation. I am aware Wyman will use and may share responses with third parties to market Teen Outreach Program ® to increase awareness and funding and that Wyman will not disclose my child’s identifying information to third parties or program staff. I also understand that the associated risks for my child to participate in this survey are minimal and will not exceed any discomfort that may be found in any daily life situations when answering routine survey questions.
_____Yes _____ No
If you have questions about the insert name of program , please contact insert contact name and number for your program.
If you have questions about the evaluation of the Wyman Teen Outreach Program, please contact
Joy Sotolongo jsotolongo@appcnc.org
919-226-1880 x102. Please leave a message with the best time to reach you.
Your signature below shows you are giving permission for your son or daughter to participate in the insert name of program.
__________________________________ _____________________________________
Child’s First and Last Names Child’s Date of Birth (mm/dd/yyyy)
__________________________________ ________________________________ __________
Parent or Guardian Signature Print Name Date
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INFORMATION ON HEALTH CARE - OPTIONAL
Gaston Youth Connected aims to reduce teen pregnancy. The project also works with doctors to help them be teen-friendly, including how to talk with teens about sexual health. If you feel comfortable sharing where your son or daughter receives health care, please select ALL the doctors your child sees. If your child’s doctor is not
on the list, please feel free to add it. We want to help all doctors deliver teen-friendly services.
We will keep this information private. We will not share the name of your child or their doctor.
We will use this information to see how many youth in our programs also see a doctor who is involved in the project – and to see if other doctors are interested in learning more about teen-friendly health services.
Gaston County Health Dept.
Gaston Family Health Services
Ashley Women’s Center
Courtview GYN
Gaston Pediatrics
Other:
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If you are under 18, please have your parent or guardian sign this form.
If you are 18 years old or older and/or live independent from your parents, then you can sign on your behalf.
I,____________________________________________, understand and agree that all pictures and video of me, my child, and/or my property shot by Gaston Youth Connected staff or their designees may be shared with and used by Adolescent Pregnancy Prevention Campaign of North Carolina (APPCNC) as part of the Gaston Youth Connected project. I authorize the use of this material and my/my child’s name, likeness, and photograph for the purpose of producing, advertising, and promoting the project.
I agree that APPCNC owns the production in which said material is used and owns all results and proceeds of the use of my/ my child’s name, likeness, and photograph. I also agree that APPCNC has unlimited rights to record, license, distribute, broadcast, and exhibit this material or portions of this material and its results and proceeds or to cause others to do the same by means of any type of technology, either known or not yet known, in all territories without compensation to me.
With respect to the use of the materials described above, I do not hold APPCNC liable for any legal action that may result from my/my child’s appearance in any APPCNC production or publication.
In signing for a minor, I confirm that I am either over 18 or am the child’s parent or legal guardian.
I understand and agree that all the provisions of this document apply to me/the minor named below.
____________________________ _____________ _____________ ___________________
Signature of Parent/Guardian or Youth Older than 18 Date
__________________________________________________________
Printed Name of Parent/Guardian or Youth Older than 18
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