Survey Consent

Dear Parent/Guardian,

We are seeking your consent to allow your child to participate in a brief, anonymous survey as part of our program evaluation for grant purposes. The survey will help us improve our services and will be completed on our Club iPads.

This survey is for Club members in 3rd through 12th grade.


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1

Child's Name

2

The Tennessee Department of Education partners with the University of Tennessee Social Work Office of Research and Public Service to evaluate extended learning programs funded by (Nita M. Lowery 21st Century Community Learning Centers /Lottery for Education Afterschool Programs) grants. Part of that evaluation includes a survey for students in grades 3-12. The survey is anonymous: your child will not be asked to provide their name when they complete the survey. The survey asks about your child’s experience of the extended learning program and their response will support continued high-quality programming. Please indicate below if you consent to have your child participate in the survey.

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3

Parent/ Guardian Name

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