Consent Statements for PYN OST Programs

This document provides information about items related to program participation for which we will need your permission or consent. Only the first items are optional. All other items are required for participation in this program.

Optional for participation:

*Permission for your child to be released to walk home alone. If you do give permission, we will allow your child be to be released from the school without a parent/guardian.
*Permission for program staff to verify student information (school name, student ID#) with the school. If you do not give consent, the program will require documentation verifying this information. This only applies to the Ignite Program.

Required for participation:

Consent for your child to participate fully in all OST on-site program activities and special events without restriction, unless otherwise stated.
*Consent for your child, in the case of an accident or injury, to receive emergency medical care. The parents will be contacted as soon as possible, and the staff may act on your behalf.
*Consent for your child to receive minor first aide care from trained OST staff. You also agree to pick up my sick child immediately.
*Consent for your child may take part in field trips or excursions involving those as listed on the OST schedule, or take walks in the neighborhood under proper supervision, including possible trips to the local library or park. You will be asked to sign consent/permission forms for your child to participate in any offsite activities and to be transported via approved vehicles.
*Consent for your child to participate in OST surveys administered by PYN and our funders.
*Consent for your child and their work connected to the OST Program to be displayed in newsletters, and/ or electronic news media. Consent to have your child’s work, including name, grade level, and school displayed by the Program for the viewing of the general public.
*Consent for your child’s education records, including but not limited to test scores, report cards, and school attendance, to be shared by the School District with Research for Action for the purposes of program evaluation. This only applies to the 21st Century CLC Program. See following page for more information.

CONSENT TO RELEASE EDUCATION RECORDS UNDER FERPA

The Out-of-School programs improves the well-being of children and youth through effective academic support, enrichment, and youth development activities during non-school hours. OST programming provides safe, constructive activities to children when they are not in school and has been demonstrated to improve in school performance.

In order to assess and improve the quality of OST programs, our third-party evaluators, Research for Action (RFA) asks for permission to collect personally identifiable information from education records regarding children’s school performance. They will collect standardized test scores, report cards and school attendance, disciplinary and other relevant school records (“education records”). RFA will use these education records to measure the impact of OST programming on children’s school performance and to improve the quality of those programs.

I am the parent or guardian of the student named above (“Student”). As authorized by applicable law, including but not limited to the Family Education Rights and Privacy Act, 20 U.S.C. 1232g, and 34 C.F.R. Part 99 (“FERPA”), I consent and authorize The School District of Philadelphia (the “School District”) to release education records concerning the Student, including confidential records of the School District, to the City’s Department of Human Services, the Public Health Management Corporation, and my Student’s OST program (“Recipients”).

The School District releases these education records in connection with the student’s participation in an OST program. The School District may disclose these education records only to the Recipients, and the Recipients may share this information only with other named Recipients, and with the Recipients’ officers, staff, administrators and independent contractors under the Recipients’ control.

The Recipients may use these education records to research, study or evaluate OST programs. If I ask, the School District will provide me with a copy of the records disclosed. FERPA and other applicable laws protect the confidentiality of and your right to privacy concerning the Student’s education records. The Recipients shall keep all information concerning the Student confidential and private to the fullest extent provided by applicable laws, including FERPA. Neither The School District nor the Recipients require me to waive any rights under these laws, and I give my consent voluntarily.