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Notice of Privacy Practices for Mental Health Services

Parent/Guardian Consent Form for See the Girl: In Elementary

Parent/Guardian Name *

Girl's Full Name *

I certify that I am the legal guardian of the above named girl. *

School *

Grade *

Parent/Guardian Phone Number *

Parent/Guardian Email

Girls Home Address *

Girls Date of Birth *

Girls Race *

Girls Ethnicity *

Grant or Deny Permission

I, the undersigned, do herby grant grant or deny permission to the Delores Barr Weaver Policy Center for the following:

Section 1 *

To use the image of my child, and Their grade and age, as marked by my selection below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, voice recording, and/or video taken of my child and/or family for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the Delores Barr Weaver Policy Center’s website: www.seethegirl.org.

Section 2 *

To release information about my child’s individual needs to a referral agency such as (Full ServiceSchools, Girl Scouts) if eligible to receive additional services and supports to increase her success. This may include your child’s name, date of birth, needs she is demonstrating, as well as your contact information.

Section 3 *

To provide reporting information to the Florida Department of Juvenile Justice Prevention Web system (JJIS) on the demographics and needs of girls served through the It’s Elementary program as per grant requirements. All information will be confidential.

Section 4 *

To access the school records of my child and allow use of the information for grant reporting purposes in order to provide information including number of absences and suspensions of all girls served to funders, such as the Department of Juvenile Justice. All information will be kept confidential.

Section 5 *

To learn and share more about the needs of girls and the impact of the Policy Center services by using girls’ individual statements in whole or in part. No personal data will be shared and all statements will be anonymous. This means no names or other identifying information will be used.

Date *

I acknowledge that I understand and agree with the Youth Rights Policy and Rights and Grievance Procedure provided to me by the Delores Barr Weaver Policy Center.

Signature *

Message

Parent/Guardian Consent Form for See the Girl: In the Middle & Groups

Parent/Guardian Name *

Girl's Full Name *

I certify that I am the legal guardian of the above named girl. *

School or after school program *

Grade *

Parent/Guardian Phone Number *

Parent/Guardian Email

Girls Home Address *

Girls Date of Birth *

Girls Race *

Girls Ethnicity *

Grant or Deny Permission

I, the undersigned, do herby grant grant or deny permission to the Delores Barr Weaver Policy Center for the following:

Section 1 *

Section 2 *

Section 3 *

Section 4 *

To access the school records of my child and allow use of the information for grant reporting purposes in order to provide information including number of absences and suspensions of all girls served to funders such as (the Department of Juvenile Justice). All information will be kept confidential.

Section 5 *

Date *

I acknowledge that I understand and agree with the Youth Rights Policy and Rights and Grievance Procedure provided to me by the Delores Barr Weaver Policy Center.

Signature *

Message

Referral Form for See the Girl: In the Community & Open Doors serving victims of sex trafficking

Consent and Referral forms

Grant or Deny Permission

Grant or Deny Permission

Referral Form for See the Girl: In the Community & Open Doors serving victims of sex trafficking

I am referring myself.

I am referring someone else.

All fields listed below are for the person you are referring.