MONTGOMERY COUNTY COMMUNITY YOUTH SUPPORT & ENGAGEMENT PROGRAM CONSENT FORM

I consent to have  my child, (Print Name) ______________________ participate in the Montgomery County Community Youth Support and Engagement Programs (MoCoCYSE Programs). The participant assumes all risks associated with participation in MoCoCYSE programming. Montgomery County Public Schools (MCPS), Montgomery County Collaboration Council (MCCC), and MoCoCYSE contracted program providers assume no liability for injury or damages arising from participation in the program. The participant consents to emergency treatment. If the participant is a minor, the parent or guardian approves his/her participation in the program. Neither the instructors nor any of the staff affiliated with MCCC and MoCoCYSE contracted program providers   are responsible for children prior to or after the scheduled programs.

I consent to the use of any photographs taken or videos made of the program for promotional and educational purposes by MCCC, MCPS, and MoCoCYSE contracted program providers.

I consent to MCCC and MCPS sharing information about my child as described below to evaluate the effectiveness of MoCoCYSE programs.

MCCC will share the following information about your child with MCPS:

• Student name; Student ID number; Number of MoCoCYSE programs enrolled per session; and MoCoCYSE program attendance.

MCPS will match the information from MCCC with the following information from your child’s student record:

• Student demographics (gender, grade, and race/ethnicity);
• Student enrollment in special services (Free and Reduced-Price Meals (FARMs), English for Speakers of Other Languages (ESOL), and Special Education);
• Number of school days enrolled in each marking period;
• Number of absences for each marking period; and
• Percent of school days attended for each marking period

MCPS will then share the above information from your child’s student record with MCCC after removing all references to student name and student ID number. MCPS will also use information shared by MCCC to match the shared information with student grades, academic assessment scores, and attendance to evaluate  the  impact  of  MoCoCYSE  programs  on  improving  students’   academic  outcomes.  The results of MCPS’ evaluation  will  be  reported  to  MCCC  in  summary  fashion,  with  no  individual students identified. MCPS, MCCC, and MoCoCYSE contracted providers will not share your child’s personal information with any other entity and will take steps to safeguard the information at all times.

I am enrolling my child in MoCoCYSE and agree to all of the above statements.

Parent/Guardian Signature                                                                                                                                                                       Date                                                                                        

Please check here if you:

Checking either box does not affect your child’s participation in MoCoCYSE programs

If you have any questions, please call your child’s MoCoCYSE program leadership team.