21st CCLC youth interview - parental permission form

Dear Parent or Guardian,

This summer the 21^st Century Community Learning Center your child attends will be piloting a six-activity, science-related program called “Making” developed by the New York Hall of Science. Making is the process of designing and developing physical objects that blend high and low technologies in unique ways.

Your child may be asked to participate in a short interview about his/her experience after the Making program. The New York Hall of Science is interested in learning about your child’s experience with these activities and his/her interest in participating future activities like these. The New York Hall of Science has contracted Education Development Center (EDC), an independent non-profit organization, to conduct the interviews. The interview questions have been approved by the New York Hall of Science.

If selected, your child’s participation in the interview is completely voluntary. The interview will be conducted at the 21^st CCLC after the final Making activity. The interview will take approximately 10 minutes to complete and your child’s responses will remain completely anonymous, and confidential unless required by applicable law. While the interview will be audio recorded, your child will not be asked to provide his/her name or any other identifying information.

In addition to securing your permission, your child will be asked if they would like to take part in the interview. Only those youth who want to participate will be included. You are free to withdraw your permission for your child’s participation at any time and for any reason.

If you give permission for your child to participate in an interview, please return the form below to [name of key contact at 21^st CCLC]. If you have any questions or concerns about your child’s rights as an interview participant or would like to offer input, you can contact the study lead, Erin Stafford, at EDC or EDC’s Office of Human Protections.

Please note that EDC will be analyzing the interviews. All interview data will be kept confidential.

Thank you,

Erin Stafford EDC Office of Human Protections

Research Associate, EDC 617-618-2731

estafford@edc.org

Instructions: The parent or guardian should complete and return this form to [Key Contact] to give permission for their child to participate in a Making youth interview.

I give consent for my child to participate in an interview._____ (Parent’s initials)

Name of Child (Printed): _________________________________________________________________

Name of Parent/Guardian (Printed): _______________________________________________________

Signature of Parent/Guardian ________________________________________ Date________________