Our After School Program

English is not your first language, is there an English-speaking adult (family member or friend) whom we can contact regarding your child’s progress? If so, list their name and phone number:

Any changes to this list must be provided in writing to Citizen Schools.

Consent for Emergency Medical Care

In case of an emergency, in the event that I or the Emergency Contact I’ve listed cannot be reached, I give permission to the medical personnel selected by Citizen Schools staff to provide medical treatment required by my child. To provide that medical treatment, I grant permission to release my child’s medical records.

Field Trips/Explorations

I give permission for my child to attend all trips associated with the program. This includes apprenticeships and field trips that may involve walking and travel by public transportation and/or private bus. These trips may occur on non-program days. I understand that Citizen Schools will provide appropriate supervision.  I will not hold the program responsible for accidents or injuries that may occur.

Apprenticeship WOW! Participation

I understand that my child will have up to two apprenticeship final presentations (known as WOW!s) per semester and his/her participation is critical to the learning process and to the project’s overall success.  I am aware that such events may occur outside of program hours and commit to ensuring my child’s attendance. I will communicate any unforeseen conflicts to my child’s team leader at least 2 weeks prior to the event.

Photographs/Video/Internet

I hereby give permission for my child’s photograph to be taken and for him/her to be captured on video in connection with the activities of Citizen Schools and to be used in newspaper and magazine articles, on television and other presentations concerning the program, or on the internet.  I understand that my child would only be identified by first name, if at all.  I understand that my child, identified only by first name or as a member of a group, may also be included on video streams of events (such as WOW! Presentations) over the Internet that are organized and supervised by Citizen Schools staff.  I give permission for the following information to be made available publicly, at the discretion of Citizen Schools:

• My child’s first name and/or picture
• Video of students in a group
• My child’s intellectual property (such as artwork, poetry, essays, performanances)

Citizen Schools requests your permission to collect and use information about your child’s participation and performance in Citizen Schools programs and in school. Citizen Schools uses this information to examine the influence of Citizen Schools’ programming on student achievement and engagement during and after your child’s participation in Citizen Schools (in middle school, high school and college). This information will help Citizen Schools improve its program in order to have an even greater impact on the students served.

 

Data Collected Directly by Citizen Schools

Information about your child will be collected directly by Citizen Schools staff or by evaluators or researchers contracted by Citizen Schools. If you provide your consent, the following information will be used for program evaluation:

• Information about your child’s background obtained from this enrollment form;
• Information collected by Citizen Schools about your child’s program attendance, his or her performance on academic skills assessments conducted during the Citizen Schools program, and his or her survey responses.

 

Data Obtained from External Sources

If you provide your consent, electronic data, records, and/or documentation about your child will be shared with Citizen Schools by your child’s school, school district, state Department of Education, or the National Student Clearinghouse (a national database of students’ college enrollment and completion). This information describes your child’s demographics, school enrollment and attendance, program participation, in and out of school suspension records, and academic performance (including course grades and state test scores) in grades 5 (prior to your child’s enrollment in Citizen Schools) through 12. Additionally, this information describes your child’s enrollment in and completion of college.  Citizen Schools will collect your child’s state-assigned or locally-assigned student identification number from your child’s school to be used to access these academic records.

 

How Information Is Used

The only persons authorized to access your child’s information will be trained Citizen Schools staff, contractors, and/or trusted partner organizations that have agreed in writing to maintain the confidentiality of student information as required by the Family Educational Rights and Privacy Act (FERPA).  Citizen Schools may use or disclose information in aggregate form to further the purpose discussed above.  However, no child will be identifiable through information provided in any report or public document.