Buses leave the school around 5:20 pm. If a child is on the bus list (if you selected “My child will be riding home on the bus" below), a signed note from the parent/guardian must be provided each time they will NOT be riding the bus home. BUS STUDENTS MAY NOT WALK OR CAR RIDE WITHOUT WRITTEN PERMISSION FROM PARENT/GUARDIAN.
If your child will be riding the bus home, what bus number do they normally ride? blanks Where is their bus stop? blank
"Funding is provided by the United States Department of Education's Nita M. Lowey 21st Century Community Learning Center Program."
Evaluation of West Virginia’s 21st Century Community Learning Center Program
Parent / Guardian Denial of Consent
I understand that the afterschool program my child will attend will be evaluated by the West Virginia Department of Education (WVDE The purpose of the evaluation study is to find out how well the program is working. What the WVDE learns from this study may help improve the program in the future. Later this school year, we would like to ask your child’s teacher about the amount of progress your child has made. Any information we would gather would be protected and your child would never be identified. The information provided would be combined with information from others and reported as a group. Allowing your child to take part in this study in the way just described will put your child at no more risk than he or she would experience during any normal day. Although your child may not benefit directly by being part of the study, it is possible that because of what we learn, the program may improve to better meet his or her needs or the needs of other students. Neither you nor your child will receive any money or other reward for taking part in this study. Allowing your child to be part of the study is completely voluntary. If you decide not to allow your child to be part of it, there will be no penalties or loss of benefits to you or your child.
To allow us to collect this information from your child’s teacher there is no action you need to take. Thank you!
If you do NOT want your child to be part of the study, just fill in the information below
and return this form to the afterschool program coordinator.
For more information about the education program we are studying, you may contact Sherry Swint at firstname.lastname@example.org. If you have questions about this evaluation study, you may contact Jonathan Rollins at Jonathan.email@example.com . This study has been reviewed and approved by the West Virginia Department of Education Institutional Review Board (IRB-WVDE-041
Parents: Keep a copy of this form for your records.
I understand that my child will be participating in a focus group of students at their 21 st Century Community Learning Center site. The West Virginia Department of Education (WVDE) is seeking feedback as part of the program monitoring system. Names and identifying characteristics will not be used in any publication of findings.Individual Information provided from the focus groups will be held in strictestconfidence, and I understand that I am free to withdraw permission for my child’sparticipation at any time by notifying the staff at my child’s before or after schoolprogram, and that there will be no negative consequences from WVDE or fromthe program as a result of this withdrawal. My signature on this consent formindicates my understanding of the focus group. The program staff member’ssignature indicates that he or she has explained the purpose of the focus groupand to inform my child that he or she may withdraw from participation at any timewith no negative consequences. If you would like a copy of this form for yourrecords, please contact your Program Director.
If you have any questions about the program, you may contact the before/afterschool program staff member named below or Sherry Swint, 21st CCLCCoordinator, at the West Virginia Department of Education (304-558-7805 Ext:3138).