Parent/Guardian Consent Form 2023-2024 (Liberty High School)

I give permission for my child to participate in Communities In Schools of Eastern Pennsylvania (CIS) programs and services in the school district while he/she is enrolled in his/her current school district and until supports are no longer needed or until I notify CIS, in writing, of my desire to withdraw my student from CIS services.

By signing this Parent/Guardian Consent/Release of Information, I authorize the following:

I give permission for my child to participate in the program. The services may include but are not limited to supportive guidance/counseling, educational support, tutoring, mentoring, and enrichment activities, and referrals, as needed. Signed releases will be obtained for parent/guardian permission in the event of referral.
I give permission for routine or emergency medical or dental treatment by any licensed medical practitioner at the closest facility to be provided in the event of illness or accident if I am unable to be reached. I further state that I will not hold CIS, the school district, or any other authorized work site, organization, or agency liable for medical treatment in case of illness, accident or any other emergency situation.
I acknowledge that this consent is voluntary and may be revoked at any time by informing CIS staff, in writing, except that prior consent will still apply to the extent that agencies have already taken action in reliance of it.
I understand that this consent form is otherwise valid for as long as my child is enrolled in his/her current school district.
I give permission for the school district to disclose my child’s Educational Records to CIS for the purposes of developing and modifying the support(s) provided to my child and to evaluate and determine the effectiveness of the program. My consent to release information is valid for as long as my child is enrolled in the school district. My child’s Educational Records will only be used as permitted under the Family Educational Rights and Privacy Act (“FERPA”) and will not be disclosed except as necessary by law. The data to be released include the following:
Attendance records, behavior records, grade reports, test scores and transcripts, demographic information, promotion/retention/graduation status, and free and reduced lunch qualifications (if available and permitted by the school in which my child is enrolled).
I acknowledge that the release of records under this consent is subject to any limitations placed by federal and state law. Signed releases will be obtained for parent/guardian permission in the event of referral.
I understand that the data and information collected on my child is maintained in a computer database. This information is used by CIS to document services provided to students and families for tracking and reporting purposes. It will be collected on a quarterly basis, and as needed. All student records may be maintained for up to 25 years.
I give permission for this form to be shared with other districts/CIS sites/CIS staff in the event my child disenrolls from this site/school/district and enrolls elsewhere.
I give permission for my child to participate in surveys and/or interviews about his/her knowledge, attitudes, or skills. I also understand that my child’s responses on surveys will be automatically grouped together with the responses of other students for any public presentations of findings, and that my child will not be individually linked to his/her responses.
I acknowledge that I have the right to inspect and that I can obtain a copy of any record released by this consent upon request in writing to the releasing agency, subject to any applicable copying costs and legal limitations.
To further my child’s academic, personal and vocational development, I will participate in parent/guardian-team conferences to discuss my child's progress (through either a home visit or a school visit) as needed.
I hereby give permission for my child to be interviewed by an external evaluator, which may include and is not limited to Educational Enterprises, LLC or Moravian College to evaluate the quality of CIS programs and services.

I understand that as the recipient of supports I or my child can file a complaint if they have a concern about the services they receive from Communities In Schools of Eastern PA, Inc. I will be encouraged to attempt to work out the problem directly with the CIS Staff, but if I cannot do that or if I am unsatisfied with the outcome I may begin the grievance procedure. I understand that Client Grievance Forms are available at all program locations, by calling the CIS office at 484-834-8830*

Yes, I understand

I give my permission to CIS to photograph, film, video and/or make sound recordings of my child, to quote, use my child’s artwork, or publish statements of my child and to use such photographs, films, video, sound recordings, artwork, and/or other statements for educational and promotional/advertising materials.*

YesNo

Communities in Schools now has an electronic platform to engage with your child for supports and assessments. The Communities In Schools Student Portal provides an additional avenue for your child to check-in and set their goals with their CIS Site Coordinator. The CIS Student Portal is helpful for ensuring that students are engaged in the process of reaching their goals and that staff have the tools and information needed to develop meaningful relationships to better address student needs. Using the CIS Student Portal, students can see their goals and CIS support activity, check-in on their progress, and request to speak with their site coordinator. Use of the CIS Student Portal is optional. I give permission for my child access the CIS Student Portal.*

YesNo

Name of Student*

Date of Birth

Date

Student Signature

Date

Name of Parent/Guardian

Parent/Guardian Signature*

Date*

Date

Home Telephone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Mobile Phone

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Name of Emergency Contact #1

Relationship to Student

Home Telephone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Mobile Phone

Please enter a valid phone number.

Name of Emergency Contact #2

Relationship to Student

Home Telephone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Mobile Phone

Please enter a valid phone number.

Parent/Guardian Consent Form

Emergency Contact Information