Youth Consent Form

Youth Assent Form

RAJO Group and Evaluation - Youth Assent Form

Form RP-101:

By completing and submitting this form, you agree to participate in the RAJO program and, if you choose, its evaluation. If you decide later you don't want to participate, just let any RAJO staff or your school principle know.

Participant Information:

First Name

Last Name

School

Grade

Phone Number

Gender

Male

Female

Birth Date

Participant's Signature

Current Date

RAJO Services AND Evaluation

I have read, understood, and accept to participate in RAJO services AND evaluations

RAJO Services Only

I have read, understood, and accept to participate in RAJO services only

Access To School Data

I agree that RAJO counsellors can access my school administrative data (such as report cards and information about my grades, attendance, and/or disciplinary incidents) with SRDC for use in the evaluation

Sharing De-Identified School Data

I agre that RAJO can share my de-identified school administrative data (such as report cards, and information about my grades, attendance, and/or disciplinary incidents) in accordance with local school/school board processes

May be contacted by RAJO staff After Program (May Include $25 Gift Card Incentive)

I accept to be contacted by RAJO staff after my participation in RAJO programs for an interview and/or focus group as part of the evaluation (interview and focus group participation will receivev a $25 gift card in recognition of their time)

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