Child Assent

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Are You Ready To Play?
CHILD ASSENT FORM (Ages 8-17)

Use the survey form below to submit your waiver which gives you permission to voluntarily participate in the Community On Demand STEAM Education & Life Skills Development game. Under the age of 13? Click here[/vc_column_text][/vc_column][vc_column width=”1/12″][/vc_column][/vc_row][vc_row css=”.vc_custom_1606689673613{margin-top: 30px !important;}”][vc_column width=”1/12″][/vc_column][vc_column width=”10/12″]

Student Information
First Name*
Middle Name
Last Name*
Child Assent
STATEMENT

My parent/guardian knows about this study and wants me to be in the study, if I want to. I do want to be in the study.

• I know that I can stop being in the study at any time I choose.

• I know that the researcher can talk about the study with my parent/guardian at any time, but will not talk about it with anyone else who is not working on the study unless I and my parent/guardian say it is okay.

• I know I can call the researcher at any time if I have any questions.
Check the appropriate space below to indicate if you want to participate.
Check the appropriate space below to indicate if you want to participate.
- Yes, I understand and want to be in the study
- No, I do not want to be in the study
- I'm not sure
Printed Signature of Child
The person obtaining consent is:

Dana Jewel Harris Executive Director NEXT Steps Youth Entrepreneur Program

CONSENT OF PARENT

My parent/guardian knows about this study and wants me to be in the study, if I want to. I do want to be in the study.

 I agree with how assent was requested and given by my child

 I agree to have my child participate in the study.

 Although my child could not give his/her assent, I agree to have my child participate in the study.

 I understand that I will be given a signed copy of this Assent/Consent Form to keep.
Consent Of Parent/Guardian
Printed Name of Parent/Guardian
Email
Relationship to child
Date
MM slash DD slash YYYY
Parent/guardian’s signature
Printed Name of 2nd Parent/Guardian
Email of 2nd Parent/Guardian
2nd Parent/Guardian's Relationship to child
2nd Parent/Guardian Date
MM slash DD slash YYYY
2nd Parent/Guardian’s Signature
Comments
This field is for validation purposes and should be left unchanged.

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The NEXT Steps Youth Entrepreneur Program is an award-winning intermediary workforce development program that specializes in creating community engagement strategies for STEAM education initiatives.

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Student Information

Consent Of Parent/Guardian

CREATE!