Positive Potential at Imagine Schools (7th/8th)

Para acceder a este formulario en español, visite: www.azyp.org/imagine-schools-formulario-de-consentimiento/

Dear Parent/Legal Guardian:

The Healthy Relationship Education Staff of Arizona Youth Partnership will be presenting Positive Potential (7/8th). Positive Potential is developed by PATH, Inc. and has been presented in schools and communities nationally as well as locally. Participants must have parental consent to attend.

Positive Potential is an evidence-based 5 or 6-lesson curriculum tailored to 6th, 7th and 8th grade students. The program encompasses a wide variety of relevant subjects such as bullying, responsible social media use, self-confidence, and risky behavior, all pertinent to the needs of students as they grow and mature. It also aims to address and prevent teen pregnancy and includes age-appropriate discussions on healthy relationships, goal setting, and sexual health related topics such as sexually transmitted diseases and contraception. To access a digital copy of the curriculum to review, please visit

https://positiveteenhealth.org/programs/positive-potential/curricula-preview-outcomes/ Password: pathblazer123*

At: Imagine Schools East Mesa Elementary School

Class: 7/8th grades

Dates: Wednesday’s, Oct. 27-Dec. 1

Your child needs your permission to participate. Please give your permission by completing the following consent form.

If you would like more information about program content or how the program is presented, please contact Dominique Cruz, Youth & Family Programs Manager at 520-744-9595 or dominique@azyp.org. Also, check out our website: www.azyp.org/program/positive-potential

AZYP has received a grant from the Arizona Department of Health Services (ADHS) to deliver the Positive Potential curriculum.  During the time your child will spend in the program, they will explore their own growth and development.  This unique program will involve your child in discussions regarding healthy relationships, goal setting, and sexual health related topics such as sexually transmitted infections and contraception. The program promotes progress in school and avoidance of behaviors which may hinder your child’s opportunities for successful growth and achievement; overall the program aims to address and prevent teen pregnancy.  All program information has been shared with and approved for delivery by the school/agency administrators. The ADHS funding provided for this program also includes a pre and post evaluation which requires parental consent.

The ADHS evaluation has been reviewed and accepted by the ADHS Human Subjects Review Board.  In compliance with the Human Subjects Review Board, no names or birthdates are collected on the evaluation and no identification numbers are assigned.  No data will be reported by individuals or classrooms.  Only aggregate (group) data will be reported so there is nothing to identify a youth who completes the evaluation.  All evaluation information will be kept confidential.  ADHS and approved contractors operate a secure environment to collect and store information from student participants enlisted in Arizona Youth Partnership programming. ADHS will collect the following types of information directly from participant evaluations:

•      Demographics – Age, race, ethnicity, gender, and county of residence

•      Health information – Pregnancy, views toward abstinence, and consequences of teen sexual activity

•      Skills – decision-making, refusal, and negotiation skills

•      Other – knowledge about healthy relationships, peer influence, self-esteem and self-efficacy

•      Opinions about their experience during their participation in the program and program satisfaction

I understand that 1) ADHS will use the participants’ responses for the purpose of program improvement, assessing whether critical program components or activities were implemented and whether they had an impact upon determinants, important behaviors and overall health goals; 2) that participating in the evaluation is voluntary and that I may elect for my child to participate or discontinue participation in the program and evaluation at any point without any risk; 3) that if consent is not provided, arrangements will be made in conjunction with school/site personnel to ensure an alternative placement is identified during program facilitation; 4) that ADHS will not require my child to disclose more information than is reasonably necessary as a condition of participation; 5) that I can request to view of the curriculum and/or evaluation tool at any time; 6) that ADHS will not share individual responses with third parties, schools personnel, parents or staff ;  and 7) that the associated risks for my child to participate in this survey are minimal and will not exceed any discomfort that may be found in any daily life situations when answering routine survey questions.

Participant Name(Required)
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Parent/ Legal Guardian Name(Required)
I give my consent to allow my child to participant in the Healthy Relationship Program(Required)
I give my consent to allow my child to participant in the ADHS Evaluation(Required)

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