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
The Children'sTrust
AGENCY/AGREEMENT:
PROGRAM NAME:
CHILD'S NAME: Last ,First MI
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 errust
ate. ,,., d,r,, i....,d:.o,.miCounty
AGENCIA/CONTRATO:
NOMBRE DEL PROGRAMA:
NOMBRE DEL NINO: Apellido ,Nombre
FECHA DE NACIMIENTO: Mes: Dia ,Ano
Permiso para ser contactado
El Fidecomiso de los Ninos financia el programa arriba mencionado y esta interesado en la
opinion de las familias participantes. Esta forma permite al Fidecomiso de los Ninos a
contactarlo/a a usted para preguntar sus opiniones acerca de los servicios que usted o su
hijo/a recibieron. El Fidecomiso de los Ninos guardara privada y confidencialmente toda la
informacian referente a su nino/a. Su opinion solamente sera usada pars mejorar los servicios.
MARQUE "Si" si usted esta de acuerdo en ser contactado v firme despues:
Si, El Fidecomiso de los Ninos puede contactarme en relacion a mi participation y
satisfaction con el programa mencionado a continuation.
Nombre:
Direction: Apt.#
Ciudad: ,Estado: ,Codigo:
Telefono de la casa: Telefono Celular:
Telefono del trabajo: - Beeper#: -
Direccion de Correo electronico:
Marque aqua si usted desea ser incluldo en la lista de correo del Fidecomiso de
Los Ninos pars recibir information referente a temas de los ninos y de los
jovenes, temas de los padres y otros topicos.
MARQUE "No" si usted no desea ser contactado v firme despuas:
NO, Yo no quiero ser contactadola por El Fldecomiso de los Ninos 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
The Children'sTrust FET TI MOUN NAN: Mwa
M&.e d 1. wynny Noe liar .l sdid'-s-d /aindk4 M Afi-r.pea Coolly
OGANIZASYON/# KONTRA:
NON PWOGRAM
NON TI MOUN: Signati ,Prenon MI
Jou ,Ane
Pemisyon pou Kontak
"The Children's Trust" bay lajan pou pwogram ki ekri an le -a, pou tot sa li to rinmin genyin
infomasyon sou fanmi kap patisipe nan li. Fom si la ap pemet "The Children's Trust" pran
kontak avek-ou pou yo ka mande-w sa-w pans& de sevis pitit ou oswa ou menm resevwa de
yo. "The Children's Trust" ap kimbe tout infomasyon sa yo sekre. Nap itilize opinion-w selman
pou nou ka fe sevis nou yo vin pi bon.
CHEKE "Yes" si ou dake you vo kontakte-w e pi siven an ba pal Ia
OUI (YES), "The Children's Trust" kapab kontakte mwen konsenan patisipasyon
mwen e pi satisfaksyon mwen avek pwogram si Ia.
Non:
Adres: Apt.#
Vil , Eta Zip KM
Telefon: - Potatif:
Telefon: Bipe#:
Adres Imail:
Choke isit si ou vie "The Children's Trust" mete non-w sou lis adres paran pou ka
resevwa infomasyon sou pwoblem ti moun ak Ia genes, pwoblem paran ak lot
sije.
CHEKE "No" si ou pa vle vo kontakte-w e pi siven an ba pal la:
NO, mwen pa vle "The Children's Trust" kontakte mwen pou pose'm kesyon
Paran/Non Gadien: Signati ,Prenork 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
O1/09/06
Re: Out -of -School Parks Grant from Children's Trust
Through City of Miami, Parks & Recreation Department