2020 Malama 21st Parent Agreement
21st Century Community Learning Center Program: Mālama Koolaupoko – Mālama Honua
Parent Agreement for Enrollments 2020-2021
*Student 1: *Student 2: *Student 3:
SECTION I: DATA COLLECTION for Evaluation
All student data will be kept confidential, and no personal identifying information will be included with the program results. The following data collected by PAF from the School will be used only to assess the effectiveness of Mālama 21st programs. All data analyses and reports, both internal and to the Department of Education, will be stripped of any identifying student information.
1. First and Last Name2. Date of Birth3. School Attending4. Teacher/homeroom teacher5. Grade Level6. 10-digit Hawai`i Dept. of Education Student ID7. Gender8. Ethnicity codes/description9. Limited English Proficiency(ELL status)/English Learner Proficiency (EL status)10. Special Needs or Disability (SPED status)11. Free/Reduced Lunch status12. Attendance records (excused/unexcused absences, tardiness)13. Final Grades14. Report Card Grades:1st, 2nd, 3rd, 4th quarter grades; % when applicable15. Hawai`i Standardized State Assessment scores16. Smarter Balanced Assessment scores
Surveys: We also request that you and your participating child/children provide information in response to surveys we distribute twice per year ( parent and student surveys, pre and post) which ask questions about your child/children’s social-emotional skills, interests in careers and academic subjects, engagement in school and out-of-school activities, familiarity with community and culture, and how they feel about their experiences in Mālama 21st.
Benefits and Risks: This study may benefit the Pacific American Foundation and the School by providing feedback that could positively influence the program structure and design. This study may benefit society if the results lead to a better understanding of how to design a place-based science program for middle and high school students with strong academic and personal outcomes. Whether or not your child chooses to participate in this study will not impact his or her relationship to the School as a student. The risks of participation are minimal.
Confidentiality and Privacy: All data will be kept confidential, in a secure location, and stored in a password-protected electronic file system. All data will be destroyed upon completion of the program and will be kept confidential to the extent allowed by law. No personal information will be included with the results.
Voluntary Participation: Participation in Mālama 21st is completely voluntary, and you and your child/children can choose freely whether to participate. At any point during the program, you or your child/children may withdraw permission with no penalty or loss of benefits to which s/he would otherwise be entitled.
Questions: If you or your child/children have any questions regarding these programs, please contact either Derek Esibill (Program Director) firstname.lastname@example.org or Anna Ah Sam (Lead Evaluator) email@example.com.
I consent to the release of my child’s/children’s student information and program records as listed above, for each student listed above.
_________________________________________________________________________________________________________SECTION II: Assumption of Risk, Release, & Indemnity AgreementFamily Form for children under 18 years of age
In consideration of the services of the Mālama 21st Program, The Pacific American Foundation (PAF) and all of the related entities, partners, agents, directors, advisors, officers, employees, representatives, volunteers, and all other persons acting on behalf of the entities listed above (collectively, hereinafter “Mālama 21st”), I hereby AGREE AND CONSENT TO WAIVE AND RELEASE, to relinquish, and to forever discharge Mālama 21st and its representatives on behalf of myself, my children, my parents, my heirs, assigns, personal representatives and estate from any and all claims, any and all causes of action that I (we) have or may have, whether past, present or future, whether known or unknown, whether anticipated or unanticipated, as follows:
As the Parent(s) or Guardian of minor children, I agree and consent to the terms and conditions set forth above. I release and discharge Mālama 21st, its representatives or agents, and all others acting on their behalf, on behalf of myself, my children, my heirs, assigns, personal representative, and the Minor’s estate for the right of the Minor being permitted by Mālama 21st to participate in the Activities and to use Mālama 21st equipment and facilities.
I release, hold harmless, and agree to defend and indemnify Mālama 21st, its representatives, agents, directors, officers, volunteers, advisors, and all other persons or entities acting on their behalf from any and all claims brought by, or on behalf of the Minor, and which are in any way connected with such use or participation by the Minor in the Activities. ____________________________________________________________________________________________________________________
For A+ Students once COVID-19 Order allows Schools Reopened: SECTION III: AUTHORIZATION FOR LATE ARRIVAL TO A+ . If my child is enrolled in A+, I hereby authorize my children to attend the Malama 21st Century Afterschool Program of Pacific American Foundation in 2020-2021 according to my child/children’s school schedule(s). I understand that the A+ Program is not responsible for my child until he/she reports to the A+ Site. I further understand that I must provide the Site Coordinator written notification in advance before making changes to my child’s schedules. _________________________________________________________________________________________________________________________________
Dated:May 28, 2020
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Document Name: 2020 Malama 21st Parent Agreement
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