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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