Teen Outreach Program® (TOP®) Consent Form
Your child has been chosen to participate in the Teen Outreach Program® (TOP®) replicated by Copper Shores Community Health Foundation and owned by Wyman Center, Inc. (Wyman). During TOP®, children will explore their growth and development, goals for the future, and goals for close and healthy relationships with others. This program has been evaluated nationally and has shown very positive results for young people. This unique program will involve your child in volunteer work in the community. This work may occur off school grounds. The program promotes progress in school and avoidance of behaviors which may hinder your child's most successful growth and achievement.

Please complete all of the information below! Thank you.
Email *
Email *
Child's Name: *
I  am the Parent or Legal Guardian of the child named above who is to participate in programs provided by Copper Shores Community Health Foundation during the 2023-24 school year. I am aware that there are potential hazards and risks involved in some programs. I am willingly allowing the child mentioned above to participate in all aspects of the program (including field trips and transportation) under the supervision of Copper Shores staff. I agree to hold harmless and indemnify Copper Shores, its Board of Trustees, and/or its employees, agents, or lessors from any and all claims by myself, my child, my heirs, my family, or my assigns.
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I give my consent to Copper Shores to use videos and/or photographs of my child across social media accounts, in promotional materials, and for any other publicity purposes. If my child’s photo is used, he/she will only be identified by his/her first name.
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I give my consent for my child to complete surveys during their TOP® Club participation. Wyman operates a secure environment to collect and store participant information from its Teen Outreach Program®. The online system also stores information about the TOP® services each student has received. Wyman collects the following types of information directly from TOP® participants through online surveys: Opinions about their experience in TOP®, ethnicity/race, gender, age, grade level, parents’ education level-Social and emotional skills, sense of self, connections with others, grades in school, skipped classes, suspensions, graduation and schooling plans, pregnancy, and parenting. I understand that Wyman and Copper Shores use the participants’ responses to improve the Teen Outreach Program®. I understand that survey and data collection is voluntary and that my child may choose not to participate at any point in the process without risk of losing TOP® services. I am also aware my child will not be required to disclose more information than is reasonably necessary to participate in Teen Outreach Program® as a condition of participation. I am aware that survey results for the entire TOP® group may be used to market Teen Outreach Program® to increase awareness and funding; results may also be used for publications or conference presentations. However, my child’s identifying information will not be disclosed except in the case where online access is unavailable and therefore paper survey data is entered by a third party or employee under a strict non-disclosure of confidential information agreement. I also understand 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.
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Please provide our signature *
Sign your name with 'e-sig' at the end.
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