Con MI MADRE Program Application

Con MI MADRE Program Application

6th-12th Grades
To fill out this form in Spanish, select language from the menu.
Para llenar este formulario en español, seleccione el idioma del menú.
Who is completing this form?*

StudentParent/GuardianTeacherCounselorOther
Does this student have a sibling in Con Mi MADRE right now?*

Yes, a sister is in the program right nowNo, but a sister used to be in the programNo

How did you hear about Con Mi MADRE?

Counselor or teacherCommunity event/ school eventCurrent/ past participantSocial mediaEl Buen SamaritanoOther

Parent & Student Authorization to Participate

Senate Bill 12, effective September 1, 2025, requires written parental consent for children to join school clubs, authorized or sponsored by school districts. [SECTION 27, new Sec. 33.0853(c) TEC] This forms grants permission for your child to sign up for or participate in any club, organization, team or group.
Student's Name*

First NameLast Name(s)
Student's School District*
Student's School ID*
Parent/Guardian Name*

First NameLast Name(s)
Permission to Participate*

I hereby grant permission for my child to participate in Con Mi MADRE during the 2026-2027 School year.
Program Participation Policy Acknowledgement*

I understand and acknowledge that Con Mi MADRE reserves the right to discontinue or terminate participation in the program if my student remains inactive in program activities for a period exceeding twelve (12) consecutive months.

Liability Waiver and Release of Claims
I, the undersigned parent or legal guardian of Student* , hereby give permission for my child to participate in Con Mi MADRE.

I understand that participation in Con Mi MADRE may involve certain risks, including but not limited to physical injury, illness, property damage, or other unforeseen risks. I acknowledge that these risks may arise from activities conducted during the program, including but not limited to classroom instruction, physical activities, transportation, and interactions with other participants.

On behalf of myself and my child, I voluntarily assume all risks associated with participation in Con Mi MADRE.

In consideration for allowing my child to participate, I hereby release, waive, discharge, and hold harmless Con Mi MADRE, its employees, interns, volunteers, and affiliates from any and all claims, liabilities, demands, damages, costs, or causes of action arising out of or related to my child’s participation in the program, including any injury, illness, loss, or damage, except in cases of gross negligence or willful misconduct.

I certify that my child is physically and medically able to participate in Con Mi MADRE and that I will inform the organization of any medical conditions that may affect participation.

I authorize Con Mi MADRE to obtain emergency medical treatment for my child if necessary, and I agree to be financially responsible for any such treatment.

I have read this Liability Waiver and Release of Claims carefully and understand its contents. I understand that I am signing this document voluntarily and that it affects my legal rights.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Data Consent for Evaluation
As part of Con Mi MADRE’s program, my child and I may be asked to share feedback or complete short assessments during the year. This helps the organization understand what families need, improve services, and measure the program’s impact.

Any personal information we provide (like our names or contact details) will be kept private and stored separately from our survey answers. Our names will never be shared in reports without our permission.

Taking part in surveys or assessments is completely voluntary. My child or I can choose not to participate or stop at any time, and this will not affect our enrollment or access to services.

All information collected will be stored securely for up to five years and will only be seen by authorized staff or approved evaluators.

If I have questions, I can contact the Data Team at data@conmimadre.org.
Data Consent for Evaluation*

I read and understand the Data Consent for Evaluation

Media Consent
Con Mi MADRE may take photos or videos of me and/or my child during program activities. These images may be used in Con Mi MADRE materials such as publications, our website, social media, digital media, educational resources, or promotional content that supports the mission.
- Photos or videos may be used with or without names when appropriate for storytelling.
- All images and recordings belong to Con Mi MADRE.
- I will not receive payment for the use of these images.
- I can change my mind at any time by sending a written request to Con Mi MADRE.
Media Consent*

I give permission for Con Mi MADRE to use photographs or recordings of myself and/or my child as described above.I do not give permission for Con Mi MADRE to use photographs or recordings of myself and/or my child as described above.

Limits of Confidentiality

Con Mi MADRE coordinators and interns keep all conversations with students and families private. However, there are a few situations where we are legally required to share information to keep someone safe. Confidentiality my be broken without permission in the following cases:
Safety Concerns (Harm to Self or Others)
- If a participant talks about wanting to hurt someone else, staff may need to warn that person and contact the authorities.
- If a participant talks about wanting to hurt themselves or expresses suicidal thoughts, staff must contact the appropriate authorities and make every effort to inform the family.
Abuse or Neglect
- If a participant shares information that suggests a child or vulnerable adult is being abused, neglected, or is at risk, staff must report this to Child Protective Services or the appropriate authorities.
Prenatal Exposure to Harmful Substances
- If a participant shares that a baby has been exposed to harmful controlled substances during pregnancy, staff are required to report this.
Parents’ Right to Access Information
- Parents or legal guardians of minors have the legal right to access their child’s records.
Limits of Confidentiality*

By checking this box, I understand and agree to the limits of confidentiality explained above.

Parent Consent for Release of Information Between School District & Con Mi MADRE

Partner/Provider Organization Name: Con Mi MADRE
Con Mi MADRE is requesting your permission to access certain school records for your student while they are participating in our program. Participation may last for more than one school year. If your student leaves the program, Con Mi MADRE’s access to their data will be removed.

With your permission, authorized Con Mi MADRE staff will be able to view your student’s information in the school district’s secure data system. The information we may access includes:

Student Information

Basic demographics: date of birth, age, gender, ethnicity, grade level, enrollment dates, services received, English Language Learner (ELL) status, and retention status.

Attendance

Days enrolled, absences, reasons for absences, and tardies (current and past years).

Grades & Coursework

Teacher names, classes, grades, teacher comments, missing assignments, graduation date, endorsement track, high school credits attempted/earned, class rank, and cumulative GPA.

Discipline

Dates, reasons, actions taken, and incident locations for all years enrolled in the district.

Standardized Test Scores

District, state, and national assessments (e.g., STAAR, ACT).

The school district and Con Mi MADRE may also share information about your student’s participation in the program.

What I Understand
- Only authorized Con Mi MADRE staff will have access to this data, and they must keep their login information private.
- This information helps Con Mi MADRE provide individualized support to my student. It may also be used for service tracking, grant reporting, and program evaluation.
- My student’s personal information will not be shared publicly. Any reports will use combined (aggregate) data without names or identifying details.
- Giving permission is optional, and I may withdraw my consent at any time.
- My student can still participate in Con Mi MADRE programs even if I choose not to share their school data.
Parent Consent for Release of Student Information*
Parent/Guardian Name

First NameLast Name(s)
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Con MI MADRE Program Application

To fill out this form in Spanish, select language from the menu.

Para llenar este formulario en español, seleccione el idioma del menú.

Household Information

Student Information

Primary Parent/Guardian Contact

Parent & Student Authorization to Participate

Liability Waiver and Release of Claims

Data Consent for Evaluation

Media Consent

Limits of Confidentiality

Parent Consent for Release of Information Between School District & Con Mi MADRE