EDGE Choosing Your Future Consent Form for Students 18 Years or Older

CHOOSING YOUR FUTURE CONSENT FORM

For Students 18 years or older

Consent for Program Participation

Choosing Your Future is an Arizona Youth Partnership (AZYP) program that helps students learn about peer pressure, media pressure, assertiveness skills and the risks of early sexual involvement. Youth also learn how to make healthy decisions, set boundaries and increase communication with trusted adults.

If you agree (give your consent) to participate in the program, you will participate in the Choosing the Best (CTB) curriculum.

Benefits of Participation: The benefit to participating in this program is that you will receive medically accurate age-appropriate sexual risk avoidance and relationship education. By participating in the program, you will learn the advantages of delayed sexual activity and be empowered to make healthy choices to improve your life outcomes.

Risks of Participation: The risks to participating are minimal but include the possibility that you may feel uncomfortable discussing or learning about topics of a personal nature. Program staff will be available to discuss feelings brought up in the process of participating in the program, and additional counseling and referrals to social service providers will be available outside this project. You may discuss these services with program staff at any time. In addition, if you are completing this consent form online, there is always a possibility of hacking or other security breaches that could threaten the confidentiality of your responses. Please know that the confidentiality of your responses to this form will be protected once AZYP downloads the data from the internet and that you are free to decide not to answer any items on this consent form.

Confidentiality: All information gathered while you are receiving services from AZYP is confidential. However, information may be released in case of medical emergency, child abuse or neglect, court order, and where otherwise legally required.

Voluntary Participation/Withdrawal: Participation in the program is voluntary. You have the right to decline or to withdraw from the program at any point. If you do not wish to participate or if you decide to stop participating in the program, it will not affect any other services you are eligible to receive.

Mandatory Reporting Requirements: All members of the staff are required by law to report suspected incidents of violence. If you report child abuse, suicidal ideation and suicidal intent, or threaten to harm others, a report must be filed with an appropriate agency. This may include Department of Child Safety or a similar agency.

Questions: If you have questions about the Choosing Your Future Program, you may contact Christine Barry at AZYP at 520-744-9595.

Consent to Participate in Program Evaluation/Data Collection (e.g. surveys)

AZYP has contracted with Civitas Evaluation, a Tucson-based consulting firm to evaluate the Choosing Your Future program. The purpose of the program evaluation is to determine if AZYP is meeting its goals, suggest areas for program improvements, and help identify plans for future programs.

If you agree (give consent) to participate in the program evaluation, you will be asked to:

  • Complete an anonymous survey before and after the CTB curriculum with questions related to your demographics; substance use; self-regulation and decision making; goal setting; healthy relationships, dating violence and sexual coercion; and overall experience in the program. You will also be asked whether you think the program affected your decisions to delay having sex.

Benefits of Participation: The benefit from participating in the program evaluation is that findings will be used to improve curriculum delivery and content and may also help inform the development of future programs in your community.

Risks of Participation: The risks to participating in the program evaluation are minimal but include the possibility that you may feel uncomfortable answering survey questions of a personal nature. Program staff will be available to discuss feelings brought up in the process of data collection, and additional counseling and referrals to social service providers will be available outside this project. You may discuss these services with program staff at any time. In addition, it is possible that your survey answers could be seen by another student or somehow revealed, which may be embarrassing for you. It is very unlikely that your answers will be revealed, and every effort will be made to keep all answers private. In addition, if you are completing this form or surveys online, there is always a possibility of hacking or other security breaches that could threaten the confidentiality of your responses. Please know that the confidentiality of your responses to this form or surveys will be protected once the data is downloaded from the internet by AZYP or its evaluator and that you are free to decide not to answer any items on this form or on surveys.

Confidentiality: All information gathered for program evaluation purposes while you are participating in AZYP programming is confidential. Survey data will be submitted to the funding agency, but the surveys will not contain your name or other personal identifiable information and the surveys will not be shared with your school or teachers. Your name and birthdate will appear on attendance records or this consent form, which are maintained by program staff, however, this information will not be shared with the funder or other staff unaffiliated with the program. Summary results from the program evaluation may be presented at meetings or in publications. AZYP staff are required by law to report suspected incidents of violence. If you report child abuse, suicidal ideation and suicidal intent, or threaten to harm others, a report must be filed with an appropriate agency. Confidential information may be released in case of medical emergency, child abuse or neglect, court order, and where otherwise legally required.

Voluntary Participation/Withdrawal: Participation in the program evaluation is voluntary. You may participate in the program without participating in the program evaluation. You have the right to decline or to withdraw from the program evaluation at any point. If you do not wish to participate or if you decide to stop participating in the evaluation, it will not affect any other services you are eligible to receive from AZYP.

Questions: If you have questions about the program evaluation/data collection activities, you may contact Meg Knight at megknight@civitaseval.com. 


EDGE Choosing Your Future Consent Form for Students 18 Years or Older

  • I have read this consent form and give my consent to participate in the following:

  • Arizona Youth Partnership (AZYP) has permission to use my name and any photographs, videos, slides, etc. of me and/or my children in stories about AZYP for the media, funding sources, and AZYP materials.
  • MM slash DD slash YYYY
  • (Needed for mailing program information or materials to students participating in remote learning)
  • MM slash DD slash YYYY
  • A copy of this form will be kept on file with AZYP. You may request to receive a copy of this form to keep.