ENFIELD PUBLIC SCHOOLS Enfield, Connecticut
6162.51 Form # 1
WRITTEN CONSENT OF STUDENT SUBMISSION TO SURVEYS, PERSONAL ANALYSIS, OR EVALUATIONS
( This form is to be used to provide as required by federal law written consent of a student’ s parent or guardian to the student’ s participation in a survey, a personal analysis, or an evaluation).
Name of Student: _______________________________________________________________ Address: ______________________________________________________________________ Grade / School Year:__________________________ Birthdate of Student: __________________ Name of Student’ s Parent or Guardian: ______________________________________________ Address of Parent or Guardian: ____________________________________________________
The survey, personal analysis, or evaluation reveals the following information:( check all those applicable)
� Political affiliations or beliefs of the student or the student’ s parent. � Religious beliefs, practices, or affiliations of the student or the student’ s parent. � Mental or psychological conditions that may embarrass the student or his / her family. � Sexual behavior and attitudes. � Illegal, anti-social, self-incriminating or demeaning behavior. � Critical appraisals of other individuals with whom the student has a close family relationship.
� Legally recognized privileged or confidential relationships, including a relationship with a lawyer, physician, or minister.
� Income( except as required by law to determine eligibility for participation in a program or for receiving financial assistance under a program).
A copy of the personal analysis, survey, or evaluation is attached for your review.
I, consent to the participation of in the
( name of parent / guardian of student)( name of student)
attached survey, personal analysis, or evaluation.
__________________________________________ ______________________________( Signature of Parent / Guardian)( Date)
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