Teen REACH Written Consent Form (pdf)
(OPTIONAL USE: If using agency generated forms - Teen REACH program must ensure these elements are covered.)
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Teen REACH Parental Consent Form
General Information
Name: Line for Information
Address: Line for Information
City: Line for Information
State: Line for Information
Zip Code: Line for Information
Date of Birth: Line for Information
Age: Line for Information
SSN (optional): Line for Information
Student school id#: Line for Information
Field Trips:
I understand that the Teen REACH program will be planning some field trips throughout the course of my child's participation. I, Line for Information will allow my child, to go on field trips with the Teen REACH program, and its staff. My child and I fully understand that all Teen REACH rules apply, even on trips. I also understand that all field trips will also have another, more detailed, permission slip, providing information concerning the exact logistics of each trip.
Photography Release: As the legal parent/guardian of Line for Information, I authorize the Illinois Department of Human Services and the local Teen REACH program operators to photograph my child for means of publication purposes. Photos might be used in various brochures and publications describing and promoting the program in a positive way. In no way will the photos be used in any illegal misrepresentation of my child.
Outcome Measurement Consent: I, Line for Information, give permission to the Illinois Department of Human Services and its designees to collect and record data on my child, this data gathering may include, but is not restricted to the following:
- Surveys and/or interviews about his/her knowledge, attitudes, skills, and behaviors in regards to risk-taking behaviors and habits, education and educational resources, positive relationships, career choices, connection to community, and overall satisfaction with the Teen REACH program.
- Academic and school deportment data from report cards and other school reports. These will be collected twice per school year.
I understand that the purpose of these surveys and interviews is to document the impact of the Teen REACH program on its participants, and to identify areas for improvement. I also understand that this information will remain private, and that only my child's site director and assigned research assistants will be able to look at his/her responses.
I understand that my child's responses will be automatically grouped together with the responses of other Teen REACH sites for any public presentations of their finding, and that my child will not be individually linked to his/her responses. In addition, I understand that I can take back my permission at any time, and that my permission automatically stops when the child leaves the Teen REACH program.
Medical Release: I understand that Teen REACH also includes physical sports and recreational activities. My child, Line for Information. has the following restrictions on his/her physical activity: Line for Information. My child takes the following medications Line for Information. These medications are: self-administered Line for Information Must be administered by an adult Line for Information My signature confirms that I have read the above information, and grants my permission for the child listed to attend, participate, and travel, as stated above.
Parent/Guardian Signature Date Line for Information
Home Phone Number: Line for Information
Work Number: Line for Information
