Con MI MADRE Program Application

The student above is my child and/or is currently under my legal guardianship. The student may participate in any and all Con Mi MADRE programs, trips, and activities for which they are eligible. In consideration of my child being permitted to attend trips and take part in Con Mi MADRE activities and the instruction my child will receive by reason thereof, I hereby relieve and release Con Mi MADRE, its sponsoring and participating universities, colleges, school districts, organizations, and their respective officers, employees, and agents, together with all those persons assisting with any phase of trips and all program activities (excluding paid certified carriers) from any and all liability, responsibilities for making trips and activities and hereby releases all of the said parties from all liability by reason of any accident, injury or other harm that may be suffered by said child while on any trip or while participating in any program activities. I agree to indemnify and hold all of the said parties harmless from all claims hereafter made by or asserted on behalf of the above-named student.

• I understand that my child and I may be invited to provide feedback and complete assessments throughout the year to support Con Mi MADRE’s program evaluation efforts.
• I understand that our responses will be used to improve services and measure program impact. All personal identifying information (such as names, addresses, or contact details) will be kept strictly confidential and stored separately from survey responses. Our names will never be associated with any reported data without consent.
• Participation in these evaluations is completely voluntary. I understand that I and/or my child may decline or withdraw from any evaluation activity at any time, without affecting our enrollment or access to program services.
• I understand that all collected data will be securely stored for up to five years and only accessible to authorized program staff or approved evaluators.
• For questions or concerns regarding this process, I may contact the Data department at data@conmimadre.org 

I understand and agree that: 

• These images may be used with or without names for captioning or storytelling purposes, when appropriate.
• All photographs and recordings will remain the property of Con Mi MADRE.
• No compensation will be provided for the use of these images.
• I may revoke this consent at any time by submitting a written request to Con Mi MADRE. 

• Duty to Warn and Protect If a participant discloses intentions or a plan to harm another person, Con Mi MADRE staff may notify the intended victim and report the information to legal authorities. If a participant expresses suicidal thoughts or a plan to harm themselves, staff are required to notify legal authorities and make reasonable efforts to inform the participant’s family. 
• Abuse of Children or Vulnerable Adults If a participant states or suggests that they are abusing—or have recently abused—a child or vulnerable adult, or if a child or vulnerable adult is believed to be at risk of abuse, staff are mandated to report this information to the appropriate social services and/or legal authorities. 
• Prenatal Exposure to Controlled Substances If a participant admits to prenatal exposure to controlled substances that may be harmful, staff are required to report this to the appropriate authorities. 
• Minors and Guardianship Parents or legal guardians of non-emancipated minors have the legal right to access their child’s records. 

Con Mi MADRE requests your permission to collect data about your student from the school district for as long as your student is an active participant in the program. Participation may include multiple school years. If your student is no longer a participant, access to the data will be removed for Con Mi MADRE staff. 

Con Mi MADRE will be granted permission to collect or view your student’s data in the school district’s electronic data system. The following specific data will be requested or viewed by the authorized Con Mi MADRE staff: 

• Demographics – date of birth, age, gender, ethnicity, grade level, district enrollment dates, and types of services received, English Language Learner (ELL) flag and retained flag. 
• Attendance (current and past school years) – days enrolled, date absent, absence reason and dates tardy. 
• Grades (current and past school years) – teacher’s names, courses, grades, teacher comments, personal development scores, missing assignments, HS graduation date, HS endorsement track, credits attempted (HS only), credits earned (HS only), class rank (HS only) and cumulative GPA (HS only). 
• Discipline (for all the years enrolled in the school district) – dates, reasons, actions, and incident location. 
• Standardized Test Scores – District, State and National standardized tests (For example – STAAR, American College Testing (ACT) etc.) 

The district and Con Mi MADRE will share information about your student’s attendance in the program. 

• I understand that data access will be granted to the authorized Con Mi MADRE staff. Each authorized staff is responsible for maintaining the confidentiality of login information and may not share access with any other individual. 
• I understand that this data will be used to provide individualized services to my student. Data may also be used, as approved, for the purpose of service tracking, grant reporting and/or program evaluation. No identifying data about my student will be published or distributed to third parties. Any reporting will be done in aggregate.  
• I understand my consent is optional and I may choose to withdraw permission at any time. 
• I understand sharing my student’s data with Con Mi MADRE is not a requirement to participate in Con Mi MADRE’s programs.