Your child is invited to participate in the ELEVATE after school program evaluation. The evaluation is being funded by a federal 21st CCLC grant awarded by the Ohio Department of Education. It is being conducted by Hatchuel Tabernik and Associates, consultants based in California. Data collected for this evaluation may include: grade, gender, race, ELL status, Special Needs status, F/R Lunch eligibility, disciplinary data, school day attendance, grades, and test scores. Information will be kept 100% confidential and will be linked to study IDs, not names. The information will be used in reports required by the state. Your child will not be identified in any way in the report. Information will be reported in aggregate form only. The information collected will help us to measure the effects of our services for children, parents and families at your school; and to develop, improve, and sustain our programming. If you do not want your child to participate in the evaluation please check the box below and return this form to your ELEVATE staff before the first day of programming. If you have any questions about this evaluation, feel free to contact: Dr. Tracee Perryman (419) 861-4400
I hereby authorize and irrevocably grant to the Center of Hope Family Services Inc. and its affiliates, licensees, agents and assigns, the unrestricted right to use and publish any part of the information that I have given to Center of Hope Family Services and the right to record my name, voice, appearance, likeness, and comments on film, videotape, audiotape, still photographs, print, and any other media now known or hereafter invented. I acknowledge that Center of Hope Family Services shall own all right, title and interest in and to this media. I further agree that Center of Hope Family Services may cause all or parts of this media to be used for any and all publications, exhibitions, public displays, editorials, advertising or other purposes. I waive any inspection or approval of the media or any advertising or publicity in which my name, voice, appearance, likeness narrative, or comments might appear. I expressly release and agree to hold harmless Center of Hope Family Services and its agents, employees, licensees and assigns from and against any and all claims including, but not limited to, invasion of privacy, that I might ever have in any way relating to my interview or its use.
Center of Hope Family Services has my permission to secure emergency transportation for my child in the event of an illness or injury that requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported. I also give Center of Hope Family Services consent to request emergency treatment for my child if needed.
I hereby certify that the statements in this application are correct and true. I understand that my child(ren)’s enrollment as a Center of Hope Family Services student is based, in part, on the information provided within this application and my agreeing to the terms as outlined in writing by Center of Hope Family Services.