COUNCIL - Planned Parenthood

Name: _____________________________________________________
Date: ______________________________________________________
COUNC IL
Application
2016–2017
Planned Parenthood Columbia Willamette
Application
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Thanks for applying and for your interest in peer education!! You can also hand your application to a current
Teen Council member and they will deliver it for you! If you have questions CALL or TEXT 503-551-4792
(Ann/Woodbrun), 503-758-0233 (Christy/Portland), or 503-729-6049 (Jana/Beaverton).
Mail
Teen Council at Planned Parenthood
- Ann Krier (Woodburn)
- Christy Alger-Williams (Portland)
- Jana Deiss (Beaverton)
3727 NE MLK Jr. Blvd.
Portland, OR 97212
E-mail
[email protected] (Woodburn)
christina.alger–[email protected] (Portland)
[email protected] (Beaverton)
Fax
503-788-7285
Our Vision:
“Our vision is to provide accurate, unbiased, and useful sexuality education; to end ignorance, promote
tolerance, and improve communication between teens and the important people in their lives.”
Who We Are:
Teen Council is made up of a diverse student body from local schools. Members come to the group with
different beliefs and viewpoints. No one is expected to already know about sexual health and prevention
issues. We strive to create a Council that is strong and varied in its membership and work actively to build
a group that is anti-racist, anti-sexist, and anti-homophobic.
What We Do:
• We create peer to peer dialogue.
• We present as volunteer educators on various topics such as HIV/AIDS,
consent & sexual assault, healthy relationships, abstinence and more!
• We act as resources by sharing sexual health information with our friends and peers.
• We participate in weekly meetings and trainings to increase knowledge and skills.
• We are part of the solution while connecting others to this important work!
To be on Teen Council you must: Please put your initials next to all that you agree to.
• Be a 10th, 11th, 12th or college freshman during the 2016/2017 school year. _______
• Have interest in providing accurate sexual health information to peers. _______
• Be responsible in budgeting time and keeping up with academic work. _______
• Be able to attend the mandatory (free) overnight retreat in September._______
• Commit to weekly meetings. (Woodburn and Portland meet Mondays; Beaverton meets Thursdays) _______
• Sometimes miss school for presentations (about one day per month). _______
• Members are expected to plan all other extra-curricular activities (work, clubs, sports, etc) around Teen
Council. If you are doing more than 1 other extra-curricular activity, please ask yourself if you really have
the time to commit to this program! _______
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Application
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_______________________________________________________________________________________________________________________________________________________________________________
Name
_______________________________________________________________________________________________________________________________________________________________________________
Address
_______________________________________________________________________________________________________________________________________________________________________________
City/State/Zip
_______________________________________________________________________________________________________________________________________________________________________________
Phone — Can you send or receive text messages? q Yes q No
_______________________________________________________________________________________________________________________________________________________________________________
Email
_______________________________________________________________________________________________________________________________________________________________________________
Parent /Guardian name(s) and relationship to you (father, mother, stepfather, stepmother, etc.)
_______________________________________________________________________________________________________________________________________________________________________________ Languages spoken at home
_______________________________________________________________________________________________________________________________________________________________________________
School
_______________________________________________________________________________________________________________________________________________________________________________
Grade you will be in next year
_______________________________________________________________________________________________________________________________________________________________________________
Current age
_______________________________________________________________________________________________________________________________________________________________________________
Birthday
Gender: ________________________________________________
Race/Ethnicity:
 African
 African-American
 Asian
 White
 Latinx/Latina/Latino
 Multi-racial
 Native American
 Other
 Pacific Islander
Preferred Pronoun:
 She/her
 Him/his
 They/their
 Ze/hir
 Other: __________________________________
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Application
Please respond to the following questions/scenarios. We want to know what you think
so please answer as honestly as you can.
1. Why do you want to be a member of Teen Council?
2. What do you hope to gain from this experience?
3. List several goals you have for yourself before you graduate. Be specific.
4. Teen Council is a big time commitment (Woodburn and Portland meet on Mondays after school;
Beaverton meets on Thursdays), how will you manage your time and other obligations? How will
you make sure that you don’t have sports, clubs, jobs or appointments on your Teen Council day?
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Application
6. What do you think are the biggest sexuality issues or concerns for teens?
7. T
he Teen Council program values diversity. How will you bring diversity, or a diverse perspective
to the group to make it stronger?
Personal Reference: Please provide the name and contact information of a reference from an educational
setting. A teacher, school counselor, coach, administrator or an adult from any other activity you know
would be great! (This should not be a parent, guardian or family friend.)
_______________________________________________________________________________________________________________________________________________________________________________
Name of Reference / Relationship to you
_______________________________________________________________________________________________________________________________________________________________________________
Reference E-mail / Reference Phone Number
Did a current Teen Council Member recruit you? If so, who? ______________________________________________________________________________
If not, how did you hear about Teen Council? ______________________________________________________________________________________________________
Have you had Teen Council come teach at your school?  Yes  No  I don’t know
Interview: We will call or text you about the interview time and date. It will be after school. Don’t worry;
it will be fun and professional! People who don’t show up to the interview may not be accepted into the
program unless something is worked out with the Teen Council Coordinator.
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Consent Form
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Dear Parent/Guardian,
We are pleased that your child is applying to be a Teen Council Peer Educator for Planned Parenthood
Columbia Willamette. This local program focuses on teen pregnancy prevention, leadership, and
community education.
The purpose of this program is to teach teens to resist peer pressure, make healthy decisions, feel good
about themselves, and set goals for the future. Research shows that teens receive a great deal of information
from other teens. Many times this information is inaccurate. Therefore, we will be training a select group of
teens with leadership potential, medically accurate, age-appropriate sexuality education, leadership skills,
and peer mentoring so that they may educate others in the community and direct them toward responsible
decision-making.
Through our program, your teen will be responsible for attending a training retreat and weekly meetings
throughout the school year to plan and implement educational activities. These activities include community
presentations, health fairs, and individual outreach. As a peer educator, your teen will help increase community
awareness, potentially help reduce teen pregnancies, and develop into a valuable community leader. You must
be very proud of your teen for having the initiative to involve themself in such a worthwhile experience.
As a parent of a peer educator, we welcome your support and input. If you have any questions,
please don’t hesitate to contact us.
Sincerely,
Ann Krier
Christy Alger-Williams
Jana Deiss
Woodburn Teen Council Coordinator
Portland Teen Council Coordinator
Beaverton Teen Council Coordinator
503.551.4792
[email protected]
503.758.0233
christina.alger–[email protected]
503.729-6049
[email protected]
Your signed consent for your teen’s participation is necessary for us to process the application.
Please fill out this form and return the original hardcopy. My child __________________________________________ has my permission to participate in the Teen Council
Peer Education Program sponsored by Planned Parenthood Columbia Willamette.
Signature of Parent/Guardian: ___________________________________________________
Date: ________________________
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Consent Form
General Medical Information
Date _____________________________________________
Teen Name________________________________________________________________________________________________________________________________________________ Date of Birth____________________________________________________________________________________ Age ________________________________________________
Parent/Guardian Name(s) ________________________________________________________________________________________________________________________
Address _____________________________________________________________________________________________________________________________________________________
City __________________________________________________________ State___________________________________________ Zip________________________________________
Phone #____________________________________________________________________________ Alt. Phone # ____________________________________________________
Other Contact________________________________ Phone #___________________________ Alt. Phone #___________________________________________
Doctor Name / Address ____________________________________________________________________________________________________________________________
Phone # _____________________________________________________________________________________________________________________________________________________
Hospital _____________________________________________________________________________ Phone Number_____________________________________________
CHECK OR FILL IN BLANKS TO ALL THAT APPLY
Does your teen have health insurance?  Yes  No
If yes, please complete health insurance information below:
Insurance Name __________________________________________ Group Number __________________________ ID number _________________________________ Is your teen allergic to any medication or products?  Yes  No
If so, what? ____________________________________________________________________________ Reaction: ______________________________________________________________
Is your teen allergic to insect bites?  Yes  No
If so, does student have an insect bite kit for emergencies?  Yes  No
If so, where does your teen keep the kit?______________________________________________________________________________________________________________
When did your teen receive their last tetanus vaccination? _________________________________________________________________________________
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Consent Form
General Medical Information
(Continued)
Does your teen have asthma?  Yes  No
If so, where does your teen keep inhaler?_____________________________________________________________________________________________________________
Does your teen have food or medication allergies?  Yes  No
If so, please specify: ______________________________________________________________________________________________________________________________________________
Does your teen take an medications?  Yes  No
If yes, current medications (prescription and over-the-counter)
Dose & schedule
please be sure that medications are in labeled containers.
My child has my permission to keep medications listed above in their possession and take
them independently  Yes  No  N/A
Planned Parenthood has permission to provide over-the-counter medications to my child for the relief of
minor pain or insect bites (i.e., Ibuprofen, Tylenol, Benadryl, hydrocortisone cream)  Yes  No
Does teen have any conditions that would keep him/her from participating in group activities requiring
moderate physical activity?  Yes  No
If so, please specify: ______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________
As a parent/guardian, I hereby give permission, in case of accident and/or emergency, to PPCW’s
Teen Council coordinators to seek medical attention for my child. I also give permission to the physician
to hospitalize, secure treatment for and to order injection, anesthesia, or surgery for my child, as named
above, according to the medical standards and expertise then and there available, whether known or
unknown. (A parent will be contacted first, whenever possible).
Parent/Guardian Signature:_______________________________________________________ Date:________________________________________________________________
(“Parent” is defined to mean one or both parents living in a teen’s household or, if parent(s) are not available because of permanent
separation from the teen, is the person legally acting in full capacity of parent.)
Signature of Teen Council Peer Educator:_________________________________________________________________ Date:________________________________
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Consent Form
Photo/Video Release Form
Occasionally Planned Parenthood’s Teen Council programs are featured for the excellent work the
teen peer educators are doing. This could include participating in promotional events, news articles,
yearbook photos, etc.
By signing this form, you consent to be photographed, filmed, videotaped or recorded, and authorize
Planned Parenthood Federation of America and all other Planned Parenthood organizations (collectively,
“Planned Parenthood”) and their authorized representatives, to use the following materials:
þ Please check all of the boxes you consent to:
 Still photographs
 Videos
 Audio tape (voice) recordings
 Peer Educator’s name
 Other
The above materials may be used in:
• Planned Parenthood’s Education, Fundraising, and Promotional Programs
• Planned Parenthood’s brochures, newsletters and publications
• Planned Parenthood’s websites and other social networking sites
• Publicity & Press materials
• Grant Reports
• Other
Name of Teen Council Peer Educator: ________________________________________________________________________________________________________________
Signature: __________________________________________________________________________________ Date :___________________________________________________________
Name of Parent/Guardian of Teen Council Peer Educator: _______________________________________________________________________________
Signature:___________________________________________________________________________________ Date:___________________________________________________________
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Consent Form
Travel Consent Form &
Vehicle Operation Liability Form
I understand that my child is participating in the Planned Parenthood Columbia Willamette’s Teen
Peer Education Program. They are responsible for their own transportation to meetings and events
during the program year. However, I also agree that my child may be transported by the program
coordinator or a responsible adult assisting with the program to community events, or program activities.
Therefore, I hereby give my permission to have my child transported for these such purposes.
Signature: ________________________________________________________________________________________ (parent or guardian)
Date: _____________________________________________________ Signature: ________________________________________________________________________________________ (participant if over 18)
Date: _____________________________________________________ ONLY FOR YOUTH WHO DRIVE THEIR OWN CARS
Name:_____________________________________________________________________________________________________________________________________________________________________
q Yes/q No
I have a valid driver’s license. State:________________ License No:____________________ Exp. Date:_______________
q Yes/q No
I carry minimum auto liability limits as required by Oregon and/or Washington State of
$25,000 per occurrence and $50,000 aggregate combined single limit of liability and
$10,000 property damage. Oregon drivers must also carry Personal Injury Protection
and Underinsured Motorist coverage.
Company:__________________________________________ Policy Number: __________________________________________
q Yes/q NoI
agree to maintain a current Oregon or Washington state driver’s license and at least the
minimum insurance required by state law for the duration of my involvement in the Teen Council.
q Yes/q No
I have been informed and understand that my insurance is the primary insurance covering my
vehicle when on Planned Parenthood Columbia Willamette (PPCW) Teen Council business.
This business does not include transportation to and from meetings and events because this
is considered commuting. I understand that while commuting, PPCW does not provide
automobile insurance coverage and agency will not be liable for damages should an accident
occur. In the event I am driving between locations and PPCW-sponsored events, I understand
that this is considered driving on PPCW business and my insurance is the primary insurance
covering my vehicle.
Signature: ________________________________________________________________________________________ Date: _____________________________________________________ Page 10
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Retreat
September
When: The retreat will be held September 23rd–25th 2016.
Where: Mt. Hood Kiwanis Camp
83500 Kiwanis Camp Rd | Government Camp, OR 97028 | 503.452.7416
Camp Kiwanis is located 53 miles east of Portland in the heart of Mt. Hood
National Forest, the Little Zig Zag River flows through camp. The camp grounds
offer beautiful views, trails, creeks and wooded slopes, creating a unique outdoor
experience for youth.
Recreation: There is space for soccer, trails to explore, a fire pit and more!
Telephone: Teen Council Coordinators will have cell phones for youth to use and
can also be contacted in the case of an emergency. Cell phone reception is limited!
Accommodations: Dormitory style sleeping accommodations furnished with
bunk bed units. Youth must provide their own bedding & towels. All meals are
home cooked and served in a scenic dining room. Please notify your teen council
coordinator of food restrictions and vegetarian/vegan preferences.
Transportation: Transportation to and from the retreat site will be organized by Planned Parenthood
Columbia Willamette. First Student Bus Company will be providing the driver and bus for transportation.
I understand that as a part of my childs training as a Peer Educator for Planned Parenthood’s Teen Council Program,
they are required to attend an overnight retreat hosted by Planned Parenthood Columbia Willamette. I give my consent
for Planned Parenthood to take them to Camp Kiwanis, 83500 Kiwanis Camp Rd, Government Camp, OR 97028. I have
read the detailed information about the Retreat on the attached document and I have had all my questions answered.
I release Planned Parenthood Columbia Willamette and their staff from any claims or liability arising out of my
child’s participation. I understand that my child will be involved in some outdoor adventure during the retreat,
including, but not limited to: hiking and team building initiatives (Challenge Course). The level of physical activity
will depend on the specific activity and teen’s ability to participate. The Challenge Course will be provided by
Team Synergo at Camp Kiwanis. You can find more details about the Challenge Course and the type of training
Team Synergo does at www.teamsynergo.com.
Signature: _____________________________________________________________ Date:__________________________
(Parent or Guardian)
Signature: _____________________________________________________________ Date:__________________________
(Participant if over 18)
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Retreat
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Challenge Course
Synergo Challenge Course
(www.teamsynergo.com)
This experiential learning environment
promises to facilitate lessons that are learned
for life and relevant to the role of being a
peer educator! Rope challenge courses are an
important tool for teaching in this age of team
building and self-development. The activities
challenge individual and group expectations,
and set the stage to explore the issues
surrounding them.
SYNERGO has been building and designing
challenge courses in the Portland area since 1982. They build courses that are creative in design, accessible to people of
all abilities, and planned with each group’s needs. They are educated in the standards put forth by the Association for
Challenge Course Technology (ACCT) and build all challenge course elements to meet these standards. Safety is their
number one priority. Challenge courses are not much help without qualified facilitators. We will have a least 4 Synergo
facilitators to provide various levels of training workshops for our teens.
Teen council members are encouraged to participate in rope course activities to the best of their ability and comfort level.
Rope challenge courses are always the high point of every teen council retreat.
About Challenge Courses
• Challenge courses are composed of a variety of different elements that fit into three general categories.
• Challenge courses are used during orientations, team building programs, school programs and curricula, and
trust building workshops, to name a few.
• The activities challenge individual and group expectations and boundaries, and set the stage to explore the
issues surrounding them.
• The Challenge course we will be using is built outdoors.
More information to follow. Please don’t hesitate to contact Coordinators with questions or concerns.
Ann Krier
Woodburn Teen Council
Coordinator
503.551.4792
[email protected]
Christy Alger-Williams
Portland Teen Council
Coordinator
503.758.0233
christina.alger–[email protected]
Jana Deiss
Beaverton Teen Council
Coordinator
503.729-6049
[email protected]
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Synergo Challenge Course
Participants Name: _______________________________________ Birth Date: ______________ Age:_____________ Address: _________________________________________________________ Phone: __________________________ Organization with which you are participating: ________________________________________________________ Health insurance Co.______________________________________ Policy #:_________________________________ Doctor’s Name: __________________________________________ Phone:___________________________________ Please read this document carefully. It must be signed by all participants in programs of Synergo. If the participant is a minor, at least one parent or guardian (parent and guardian being referred to as Parent) must also sign, as evidence of their agreement to these terms and conditions on their own behalf and on behalf of the minor participant. References in this agreement to “I” or “we” refer to all who sign below, unless otherwise indicated. PARTICIPANT AGREEMENT (Including Acknowledgment and Assumption of Risks, Agreements of Release and Indemnity, and Other Provisions) In consideration of the services of Synergo, LLC, a Limited Liability Company organized and existing under the laws of the State of Oregon ( referred to in this document as “Synergo”), I , Participant and Parent of a minor participant, acknowledge and agree, for myself and on behalf of a minor participant for whom I sign, as follows: Activities and Risks I understand that the challenge course activities conducted by Synergo, the structures and premises on which they are conducted and related equipment, may expose participants to certain risks. The activities require moderate physical exertion, and include a variety of games and initiatives, high and low challenge course elements (a variety of structures over, through and on which participants may be asked to walk, swing or climb, with or without the assistance of staff or co-­‐‑participants) and associated challenge course climbing activities. Certain of the challenge course elements may be as high as 50 feet off the ground and, while reasonable measures will be taken to prevent a fall or collision, accidents may occur. Among the hazards and risks of the activities and use of the premises and equipment are the following: falls; abrupt and possibly damaging contact with structures and other objects, and other persons; anxieties and fears associated with heights; close contact with other participants; the carelessness of participants, and misjudgments on the part of the staff of Synergo, the failure of structures and equipment; and the unpredictable forces of nature. Participants may experience an increased heart rate and other symptoms of anxiety and stress due to physical exertion, reliance on other participants, and a fear of height or of being unprotected or falling. Participants and staff may fail to follow proper procedures, instructions and the operating policies of Synergo. Injuries associated with participation in this program may include breaks, sprains, strains, bruises and other contusions and in extreme cases, emotional upset, anxiety and even death. I understand that there may be times during the training day in which participants will not be supervised by Synergo, and that Synergo has no responsibility for participant during those times, or for the general condition of the premises on which the activities are conducted, or for any activity on such premises other than the actual training activities. The description above of these risks is not complete and other unknown or unanticipated risks may result in property loss, injury or death. Engaging in these activities may require a degree of skill and knowledge different from other activities with which participants may be familiar. Participants have responsibilities for managing the risks to themselves others. The training activities are instructional in nature and participants are expected to expand and challenge their skills and judgment. Participant and Parent acknowledge that participation in this activity is purely voluntary, and with full knowledge of the inherent and other risks. Acknowledgment and Assumption of Risks Understanding the nature of the activities and their risks, and that other risks may be encountered which cannot be reasonably anticipated, I acknowledge and expressly assume all risks of the Synergo activities, whether or not described in this document, known or unknown and inherent or not. I take full responsibility for any injury or loss, including death, which I, or the minor for whom I sign, my suffer, arising in whole or part out of my, or the minor’s, enrollment or participation in the activities of Synergo.
Release and Indemnity If I am an adult Participant or the Parent of a minor Participant, I hereby agree, for myself and on behalf of the minor participant for whom I sign below, TO RELEASE, INDEMNIFY (that is, defend, protect and pay claims , including costs and attorneys fees), AND HOLD HARMLESS Synergo, its owners, officers, agents, and employees, (“Released Parties”), with respect to any and all claims of injury, disability, death, or other loss or damage to person or property suffered by me, by any member of my family, rescuers, co-­‐‑
participants, or any other person, arising in whole or part from my participation in the training or any related activity, WHETHER ARISING FROM THE NEGLIGENCE OF A RELEASED PARTY OR OTHERWISE, and to the fullest extent permitted by law. Additional Provisions I, an adult Participant or Parent of a minor Participant, authorize Synergo to provide or obtain for me, or for the minor, such medical care as it considers necessary and appropriate, and I agree to pay all costs associated with such care and related transportation. Synergo and any third party medical care giver are authorized to exchange medical information concerning my, or the minor’s, medical condition. Any dispute between a Released Party and Parent or Participant will be governed by the substantive laws of the State of Oregon (not including laws which might apply the laws of another jurisdiction), and any mediation or suit shall take place only in that state, in Multnomah County. If the dispute cannot be resolved by mutual agreement, I agree to submit it to a mediator recognized by the Courts of that State and County. I will pay all costs and attorney'ʹs fees incurred by any Released Party in defending a claim or suit brought by me, or by or on behalf of the minor participant, if the claim or suit is withdrawn or to the extent a court or mediator determines that the Released Party is not responsible for the claimed injury or loss. This agreement is entered into voluntarily, and after careful consideration. Its terms cannot be supplemented or amended except in writing. I understand and agree that it is binding, to the fullest extent allowed by law, upon all persons signing below, their respective heirs, executors, administrators, wards, minor children (whether or not they are Participants) and other family members. If any part of this agreement is found by a Court or other appropriate authority to be invalid, the remainder of the agreement nevertheless shall be in full force and effect. In emergency call: ___________________________________________ Phone: _______________________________ Signature of participant: ______________________________________ Date: _________________________________ Signature of Parent (if participant is under 18):_______________________ Date: ____________________________ TEEN COUNCIL PROGRAM OF
PLANNED PARENTHOOD
Teen Assent Form
NAME OF TEEN COUNCIL APPLICANT: _______________________________________
Date of birth (mm/dd/yyyy): ______/______/__________
About the Teen Council Program
Teen Council is a peer sexuality education program. It is made up of high school students who are trained to act as educational
resources for their peers. Members make presentations in high school and middle school classrooms, as well as other
educational community venues. An intensive training program begins with a retreat and continues with weekly meetings
throughout the school year. The program is continually evaluated using surveys to track your progress and development,
which includes questions about knowledge, attitudes and behaviors.
About the Teen Council Application Process
Teen Council often receives more applications than we can accept and acceptance into the program is a two-step process. All
applicants are interviewed to determine whether or not they are eligible for the program. If you are not eligible, you will
receive a letter indicating such and are welcome to re-apply in the future. You will not be part of the Teen Council evaluation.
If you are eligible for the program, you will move to the second step of the process where you will be randomly selected for
participation in the Teen Council program and become part of the evaluation.
About the Teen Council Evaluation
Teen Council often receives more applications than we can accept. We want you to know that we value your thoughts and
experiences whether or not you are selected for Teen Council. For this reason, all eligible applicants are asked to complete
surveys for the next three years, or until they finish high school, whether or not they are selected for participation in
the program. You do not have to take the surveys if you do not want to. On the second page of this form you will sign
whether or not you agree to take the surveys.
If you are not selected for participation in Teen Council, you will be compensated for each completed survey with $50 cash
and may take up to four surveys, if your involvement begins in the 10th grade. You will not be able to re-apply to Teen Council
if you are not selected this year.
The surveys include questions about your demographics (for example, gender and race), social and emotional competencies,
civic engagement, attitudes and beliefs about sexuality and reproductive health, comfort level discussing issues related to
sexuality and reproductive health, and specific questions about your own sexual behaviors. You may also be asked to provide
current and/or prior report cards and/or grades so that the evaluation can look at any relationship between program
participation and academic outcomes. All of the information collected is used to improve the program and will help determine
if Teen Council is an effective way to increase sexuality knowledge, reduce risk behaviors, and improve health outcomes.
There are no known risks of physical, psychological, or social harm to you for participating in the evaluation. If there are
questions that you do not want to answer, you do not have to answer them. Your name will not be disclosed with the
responses and any presentation of the data will be summarized. All data collected for evaluation purposes will be stored in
secure files, without your name attached.
In order for the research team to be able to contact you, you will be asked to provide contact information for yourself, your
friends and your family. This contact information will be used ONLY to locate you for survey administration and will not be
used for any other purpose. For example, in the event that you miss a survey, Philliber Research & Evaluation may contact
you to offer other options for completing the survey (such as by phone, email, or regular mail). You will be asked to update
this contact information with each survey and separately during the late summer/early fall (eligible youth who have not been
selected for participation in the program will be compensated with $10 for up to two separate contact information updates).
(over)
Sally Brown
Chesapeake IRB Approved Version 12 Jan 2016
If you have any questions about the Teen Council program you may contact Sarah Sutherland, Peer Education Institute
Manager at Planned Parenthood of the Great Northwest, at 206-328-7727. If you have any questions about this research study
you may contact Dr. Sally Brown, the person in charge of this research study, at 530-795-3618. If you have any questions
about your rights as a research participant you may contact Chesapeake IRB at 410-884-2900. An IRB, or institutional review
board, is an ethics committee that has reviewed this study to help ensure your rights as a research participant are protected.
__________________________________________________________________________________________________
Please check one:
_____ I willingly consent to participate in all aspects of the Teen Council program AND evaluation under the
supervision of Planned Parenthood staff. Even if I do not become, or remain, a member of the Teen Council program, I
consent to participate in the evaluation of the program if I was found to be eligible for the program. Should I change schools
during this school year, I give consent for my current school to inform the evaluation team as to the name and location of the
school to which I transferred. Even if I agree to participate, I can change my mind at any time.
_____ I do not consent to participate in the evaluation of the Teen Council program though I will participate in the
program. Not participating in the evaluation will not impact whether or not I am selected to participate in the program.
_____ I do not consent to participate in the program OR evaluation of the Teen Council program.
____________________________________________
Signature
____________________________
Date
____________________________________________
Printed Name
____________________________
Date
Sally Brown
Chesapeake IRB Approved Version 12 Jan 2016
TEEN COUNCIL PROGRAM OF
PLANNED PARENTHOOD
Parent/Guardian Consent Form
NAME OF TEEN COUNCIL APPLICANT: _______________________________________
Date of birth (mm/dd/yyyy): ______/______/__________
About the Teen Council Program
Teen Council is a peer sexuality education program. It is made up of high school students who are trained to act as educational
resources for their peers. Members make presentations in high school and middle school classrooms, as well as other
community venues. An intensive training program begins with a retreat and continues with weekly meetings throughout the
school year. The program is continually evaluated using surveys to track your child's progress and development, which
includes questions about knowledge, attitudes and behaviors.
About the Teen Council Application Process
Teen Council often receives more applications than we can accept and acceptance into the program is a two-step process. All
applicants are interviewed to determine whether or not they are eligible for the program. If your child is not eligible, they will
receive a letter indicating such and are welcome to re-apply in the future. They will not be part of the Teen Council evaluation.
If your child is eligible for the program, they will move to the second step of the process where they will be randomly
selected for participation in the Teen Council program and become part of the evaluation.
About the Teen Council Evaluation
We want you to know that we value your child’s thoughts and experiences whether or not they are selected for Teen Council.
For this reason, all eligible applicants are asked to complete surveys for the next three years, or until they finish high
school, whether or not they are selected for participation in the program. Your child does not have to take the surveys if
they do not want to. On the second page of this form, you will sign whether or not you allow your child to take the surveys.
Those who are not selected for participation in Teen Council will be compensated for each completed survey with $50 cash
and may take up to four surveys, if their involvement begins in the 10th grade. They will not be able to re-apply to Teen
Council if they are not selected this year.
These surveys include questions about your child’s demographics (for example, gender and race), social and emotional
competencies, civic engagement, attitudes and beliefs about sexuality and reproductive health, comfort level discussing issues
related to sexuality and reproductive health, and specific questions about their own sexual behaviors. Your child may also be
asked to provide current and/or prior report cards and/or grades so that the evaluation can look at any relationship between
program participation and academic outcomes. All of the information collected is used to improve the program and will help
determine if Teen Council is an effective way to increase sexuality knowledge, reduce risk behaviors, and improve health
outcomes.
There are no known risks of physical, psychological, or social harm to your child for participating in the evaluation. If there are
questions that your child does not want to answer, your child does not have to answer them. Your child’s name will not be
disclosed with the responses and any presentation of the data will be summarized. All survey data collected for evaluation
purposes will be stored in secure files, without your student’s name attached.
In order for the research team to be able to contact your child, your child will be asked to provide contact information for
themselves, friends and family. This contact information will be used ONLY to locate them for survey administration and will
not be used for any other purpose. Your child will be asked to update this information with each survey and separately during
the late summer/early fall (eligible youth who have not been selected for participation in the program will be compensated
with $10 for up to two separate contact information updates).
(over)
Sally Brown
Chesapeake IRB Approved Version 12 Jan 2016
If you have any questions about the Teen Council program you may contact Sarah Sutherland, Peer Education Institute
Manager at Planned Parenthood of the Great Northwest, at 206-328-7727. If you have any questions about this research study
you may contact Dr. Sally Brown, the person in charge of this research study, at 530-795-3618.
GETTING ANSWERS TO YOUR QUESTIONS OR CONCERNS ABOUT THE STUDY
You can ask questions about this consent form or the study (before you decide to start the study, at any time during the study,
or after completion of the study). Questions may include:
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Who to contact in the case of a research-related injury or illness;
Payment or compensation for being in the study, if any;
Your responsibilities as a study subject;
Eligibility to participate in the research;
The study doctor’s or study site’s decision to exclude you from participation;
Results of tests and/or procedures;
Other questions, concerns, or complaints.
Contact the study doctor or study staff listed on the first page of this form with any questions, concerns or
complaints
GETTING ANSWERS TO YOUR QUESTIONS ABOUT YOUR RIGHTS AS A RESEARCH SUBJECT
This study has been reviewed by an Institutional Review Board (IRB). This Committee reviewed this study to help ensure that
your rights and welfare are protected and that this study is carried out in an ethical manner.
For questions about your rights as a research subject, contact:
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By mail:
Study Subject Adviser
Chesapeake IRB
6940 Columbia Gateway Drive, Suite 110
Columbia, MD 21046
or call toll free:
877-992-4724
or by email:
[email protected]
Please reference the following number when contacting the Study Subject Adviser: Pro00015438. . An IRB, or institutional
review board, is an ethics committee that has reviewed this study to help ensure your child’s rights as a research participant are
protected.
Sally Brown
Chesapeake IRB Approved Version 12 Jan 2016
I, the undersigned, am the Parent or Legal Guardian of______________________________________.
_____ I willingly allow my child to participate in all aspects of the Teen Council program and evaluation under the
supervision of Planned Parenthood staff. Even if my child does not become a member of the Teen Council program but is
found to be eligible for the program, I willingly allow my child to participate in the evaluation of the program. Should my child
change schools during this school year, I give consent for my child’s current school to inform the evaluation team as to the
name and location of the school to which my student transferred. Even if I agree to have my child participate, I can change
my mind at any time.
_____ I do not allow my child to participate in the evaluation of the Teen Council program though I consent to my child
participating in the program. Not participating in the evaluation will not impact whether or not my child is selected to
participate in the program.
_____ I do not allow my child to participate in the program OR evaluation of the Teen Council program.
____________________________________________
Parent/Guardian Signature
Sally Brown
____________________________
Date
Chesapeake IRB Approved Version 12 Jan 2016