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CIS PARENT CONSENT / RELEASE OF INFORMATION

School Year 2022-2023

Thomas MS (912-077)


Consent to Participate:

1. I give permission for my child (name): to participate in the Communities In Schools (CIS) program for the 2022-2023 school year. Services my child may receive include but are not limited to supportive guidance/counseling, educational support, tutoring, mentoring, enrichment activities, referrals to other agencies, and other.

2.I give permission for my child to complete surveys and/or assessments administered by CIS to guide service planning and determine progress, and give permission for CIS to use [on an anonymous basis] the responses to surveys and/or assessments in promotional materials and content for CIS .

3. I acknowledge that this consent is voluntary and may be revoked at any time by informing CIS staff, in writing, except that prior consent will still apply to the extent that agencies have already acted in reliance of it.

4. I give permission for my child to participate in field trips and other activities sponsored by CIS. Private transportation may be used in these and other activities.

5. I give permission for routine or emergency medical or dental treatment by any licensed medical doctor to be provided in the event of illness or accident if I am unable to be reached.

Consent to Release of Information:

6. I give permission for CIS to provide and obtain the following information about my child (name): from the school, school district, the Texas Education Agency and/or the CIS National Office: demographics, grade reports, attendance records, test scores, disciplinary information, class schedules, identification numbers, free/reduced lunch status, health-related information, special education information, interventions and services provided, survey responses and other.

7. I acknowledge that the information provided and obtained may be used to plan and adjust services that will help my child, for tracking and reporting purposes, and to evaluate and determine the effectiveness of the CIS program.

8. I acknowledge that the records and information released under this consent will be kept confidential to the extent permitted by law and used only for the purpose indicated.

9. I acknowledge that the release of records under this consent is subject to any limitations placed by federal and state law.

10. I acknowledge that this consent allows release of data for the school year listed above. Data from this year will be retained for up to five to seven years and may be shared during that time for evaluation purposes or to provide services that will help my child.

11. I acknowledge that the records released concerning the student may contain references to other persons (i.e., members of the student’s family).

12. I understand that the data and information collected on my child including documentation of services provided to my child is maintained in a secure computer database and a case file. I authorize CIS to maintain the information provided for the purposes noted above in the CIS computer database and case file.

13. I acknowledge that I have the right to inspect or obtain a copy of any record released by this consent upon request in writing to the releasing agency, subject to any applicable copying costs and legal limitations.

14. In addition, I give permission for CIS to provide and/or obtain the above information and other information noted below from the following individuals or organizations (see #14 Continued below to enter Individual/Organization).

15. I acknowledge receipt of the CIS Participant Rights.

My signature below gives permission for my child to participate in the CIS program. My signature authorizes CIS to obtain the above types of information related to my student and to provide the above types of information to the school, school district, Texas Education Agency, CIS National Office and/or the released agents identified above.

I release Communities In Schools and its employees, volunteers, or agents from liability for accidents, injuries, or illnesses that may occur to my child during his/her participation in the program. My child and I understand that we are voluntarily participating in the Communities In Schools program.

Date: July 12, 2024


Please select who will be participating...
Minor
Continue
First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

School Code 00-


Student ID *

MEDIA RELEASE

CIS may use my image as explained herein. I understand that CIS may take and use photographs, digital or other recordings, or other images of me participating in the Program as part of its fundraising and marketing efforts. I consent to CIS's use of my image for these and similar purposes, whether in printed materials, on the Internet, or in any other medium, without any time limitation. I understand that CIS is not obligated to compensate me for such use of my image*

OPT IN FOR TELEWORK COMMUNICATION

I give my permission for CIS to contact me and my child (in middle/high school) via text-messaging.*

OPT IN AUDIO-VIDEO CONFERENCING PLATFORM

I give my informed consent for CIS employee to communicate with me using Audio-Video Conferencing Platform*

I am aware that I can opt out of this current communication agreement with CIS at any time.

I understand that CIS will use the checked communication platform during scheduled business hours only (8:00AM - 4:00PM).

#14 CONTINUED


Individual/Organization

Individual/Organization
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
County
County*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

School Code 00-


Student ID *

MEDIA RELEASE

CIS may use my image as explained herein. I understand that CIS may take and use photographs, digital or other recordings, or other images of me participating in the Program as part of its fundraising and marketing efforts. I consent to CIS's use of my image for these and similar purposes, whether in printed materials, on the Internet, or in any other medium, without any time limitation. I understand that CIS is not obligated to compensate me for such use of my image*

OPT IN FOR TELEWORK COMMUNICATION

I give my permission for CIS to contact me and my child (in middle/high school) via text-messaging.*

OPT IN AUDIO-VIDEO CONFERENCING PLATFORM

I give my informed consent for CIS employee to communicate with me using Audio-Video Conferencing Platform*

I am aware that I can opt out of this current communication agreement with CIS at any time.

I understand that CIS will use the checked communication platform during scheduled business hours only (8:00AM - 4:00PM).

#14 CONTINUED


Individual/Organization

Individual/Organization
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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