Informed Consent Form for Legal Guardian(s)
Project Title: Program of Evaluation- Light of Chance, Inc.: Breathe Youth Arts Program
Investigator(s): Dr. Holli Drummond, WKU Department of Sociology & Criminology holli.drummond@wku.edu; 270-745-2259
Your child is being asked to participate in a project conducted through Western Kentucky University and the Light of Chance non-profit organization. The University requires that you provide a signed agreement for your child to participate in this project.
Below, we explain the purpose of the project, the procedures to be used, and the potential benefits and possible risks of participation. After reading the following information, you may ask any questions you have to help you understand the project by contacting the researcher at the email address or phone number listed above.
If after reading about the project, and asking follow-up questions of the researchers, you decide that your child can participate in the project, please sign and return this form (a copy will be provided for your records).
1. Nature and Purpose of the Project: This program evaluation seeks to observe the impact of the Breathe program on the participating students. In an effort to understand the effectiveness of the program, we seek your permission to interview your adolescent dependent throughout the course of the program.
2. Explanation of Procedures: Throughout the course of the program, your child will partake in various sessions through the Breathe program. So that we can understand the benefit of these sessions, your child will be asked to provide feedback at three points during their participation by completing an online survey.
3. Discomfort and Risks: There are no perceived risks, we assure that the information gathered will remain confidential. At any point, if a participant or their parent feels uncomfortable or feels uncomfortable or at-risk they can stop with no penalties.
4. Benefits: In evaluating the strengths and weakness of this program, you are involved in helping the program reach its full potential.
5. Confidentiality: Confidentiality will be protected as the information collected will be stored on a password-protected computer. Records will be viewed, stored, and maintained in private, secure files only accessible by the research team for three years following the study, after which time they will be destroyed.
6. Refusal/Withdrawal: Refusal to participate in this study will have no effect on any future services you may be entitled to from the University. Anyone who agrees to participate in this study is free to withdraw from the study at any time with no penalty.
You understand also that it is not possible to identify all potential risks in an experimental procedure, and you believe that reasonable safeguards have been taken to minimize both the known and potential but unknown risks.