HomeMy WebLinkAboutExhibit 4ATTACHMENT C:
CONSENT TO CONTACT FORM
(English, Spanish, Creole)
Form of PSA with not -for -profit organizations
01/09/06
Re: Out -of -School Parks Grant from Children's Trust
Through City of Miami, Parks & Recreation Department
AGENCY/AGREEMENT:
PROGRAM NAME:
CHILD'S NAME: Last ,First MI
The Children'sTrust CHILD'S DATE OF BIRTH: Month Day ,Year
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Permission for Contact
The Children's Trust provides funding for the above program and is interested in input from
participating families. This form allows The Children's Trust to contact you to ask your opinions
about the services you and/or your child received. The Children's Trust will keep all information
regarding your child confidential and private. Your feedback will only be used to improve
services.
CHECK "Yes" if you agree to be contacted and sign below:
YES, The Children's Trust may contact me regarding my participation and
satisfaction with the program listed above.
Name:
Address: Apt.#
City , State Zip Code
Home Phone: Cell Phone:
Work Phone: - Beeper#:
Email Address:
Check here if you want to be added to The Children's Trust parent mailing
list to receive information regarding child and youth issues, parenting, and
other topics.
CHECK "No" if you do not want to be contacted and sign below:
NO, I do not want The Children's Trust to contact me for my input or
opinions.
Parent/Guardian's Name: Last ,First MI
PLEASE PRINT
Form of PSA with not -for -profit organizations
01/09/06
Re: Out -of -School Parks Grant from Children's Trust
Through City of Miami, Parks & Recreation Department
#
Signature: Date:
Form of PSA with not -for -profit organizations
01/09/06
Re: Out -of -School Parks Grant from Children's Trust
Through City of Miami, Parks & Recreation Department
The Children sTrust
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AGENCIAICONTRATO:
NOMBRE DEL PROGRAMA:
NOMBRE DEL NINO: Apellido ,Nombre
FECHA DE NACIMIENTO: Mes: Dia ,Arlo
Permiso para ser contactado
El Fidecomiso de los Nii os financia el programa arriba mencionado y este interesado en Ia
opinion de las families participantes. Este forma permite al Fidecomiso de los Nirios a
contactarlo/a a usted pars preguntar sus opiniones acerca de los servicios que usted o su
hijo/a recibieron. El Fidecomiso de los Nirios guardara privada y confidencialmente toda Ia
informacifn referente a su nifio/a. Su opinion solamente sera usada pars mejorar los servicios.
MARQUE "Si" si usted esta de acuerdo en ser contactado v firme despuos:
Si, El Fidecomiso de los Niiios puede contactarme en reiacion a mi participacion y
satisfaccion con el programa mencionado a continuacion.
Nombre:
Direccion: Apt.#
Ciudad: ,Estado: ,Codigo:
Tel€fono de la casa: - Telefono Celular:
Telefono del trabajo: - Beeper#: -
Direccibn de Correa electronico:
Marque aqui si usted desea ser incluido en la lista de correo del Fidecomiso de
Los Nilios para recibir informacion referente a temas de los nirios y de los
jovenes, temas de los padres y otros tbpicos.
MARQUE "No" si usted no desea ser contactado v firme despuos:
NO, Yo no quiero ser contactado/a por El Fldecomiso de los Ni#ios para obtener mis
opiniones.
Nombre del Padre/Guardian:
Apellido: ,Nombre:
Escriba en tetra de imprenta
Form of PSA with not -for -profit organizations
01/09/06
Re: Out -of -School Parks Grant from Children's Trust
Through City of Miami, Parks & Recreation Department
Firma: Fecha:
Form of PSA with not -for -profit organizations
01/09/06
Re: Out -of -School Parks Grant from Children's Trust
Through City of Miami, Parks & Recreation Department
OGANIZASYON/# KONTRA:
NON PWOGRAM :
NON Ti MOUN: Signati ,Prenon MI
The Chiidren'sTrust FET TI MOUN NAN: Mwa
Imirklai • to Apron* thriller I, atahm ow Awakes if IllarAPeare Ginty
Jou ,Ane
Pemisyon pou Kontak
"The Children's Trust" bay lajan pou pwogram ki ekri an le -a, pou tet sa li to rinmin genyin
infdmasyon sou fanmi kap patisipe; nan Ii. Fain si la ap pemet "The Children's Trust" pran
kontak avek-ou pou yo ka mande-w sa-w panse de sevis pitit ou oswa ou menm resevwa de
yo. "The Children's Trust" ap kimbe tout info masyon sa yo sekre. Nap itilize opinion-w selman
pou nou ka fe sevis nou yo vin pi bon.
CHEKE "Yes" si ou dake ;mu vo kontakte-w e pi siven an ba pal Ia
OUI (YES), "The Children's Trust" kapab kontakte mwen konsei#nan patisipasyon
mwen e pi satisfaksyon mwen avek pwogram si Ia.
Non:
Adres: Apt.#
Vil , Eta Zip Ke d
Telefon: - Potatif: -
Telefon: - Bipe#: -
Adres (mail:
Choke isit si ou vie "The Children's Trust" mete non-w sou lis adres paran pou ka
resevwa info masyon sou pwobiem ti moun ak Ia genes, pwoblem paran ak lot
sije.
CHEKE "No" si ou Pa vle vo kontakte w e DI siven an ba pal la:
NO, mwen pa vie§ "The Children's Trust" kontaktO mwen pou pose'm Mayon
Paran/Non Gadien: Signati
,Prenon MI
SOUPLE AN GROS LET
Signati: Date:
Form of PSA with not -for -profit organizations
01/09/06
Re: Out -of -School Parks Grant from Children's Trust
Through City of Miami, Parks & Recreation Department
Form of PSA with not -for -profit organizations
01/09/06
Re: Out -of -School Parks Grant from Children's Trust
Through City of Miami, Parks & Recreation Department