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 CHILD'S DATE OF BIRTH: Month
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AGENCY/AGREEMENT:
PROGRAM NAME:
CHILD'S NAME: Last ,First MI
Day ,Year
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
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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AGENCIA/CONTRATO:
NOMBRE DEL PROGRAMA:
NOMBRE DEL NII IO: 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 pars preguntar sus opiniones acerca de los servicios que usted o su
hijo/a recibieron. El Fidecomiso de los Ninos guardare privada y confidencialmente toda la
informacion referente a su nino/a. Su opinion solamente sera usada para mejorar los servicios.
MARQUE "Si" si usted esta de acuerdo en ser contactado y firme despues:
Si, El Fidecomiso de los Ninos puede contactarme en rellacion a mi participation y
satisfaction con el programa mencionado a continuacion.
Nombre:
Direction: Apt.#
Ciudad: ,Estado: ,Codigo:
Telefono de la case: - Telefono Celular:
Telefono del trabajo: Beeper#:
Direccion de Correo electronico:
Marque aqui si usted desea ser incluido en la lista de correo del Fidecomiso de
Los Ninos para recibir informacion 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 y firme despues:
NO, Yo no quiero ser contactado/a por El Fidecomiso de los Ninos para obtener mis
opiniones.
Nombre del Padre/Guardian:
Apellido: ,Nombre:
Escriba en tetra de Imprenla
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
O.d'e.hda. *meow M. AW of rhlltrm end /ani+u w Now -lade Away
OGANIZASYON/# KONTRA:
NON PWOGRAM :
NON TI MOUN: Signati ,Prenon MI_,�___
Jou ,Ane
Pemisyon pou Kontak
"The Children's Trust" bay Iajan pou pwogram ki ekri an le -a, pou tet sa li to rinmin genyin
infomasyon sou fanmi kap patisipe nan 11. Fom si la ap pemet "The Children's Trust" pran
kontak avek-ou pou yo ka mande-w sa-w panse de sevis pith ou oswa ou menm resevwa de
yo. "The Children's Trust" ap kimbe tout infomasyon sa yo sekre. Nap itilize opinion-w seaman
pou nou ka fe sevis nou yo vin pi bon.
CHEKE "Yes" si ou dako pou vo kontakte-w e pi siven an ba pal la
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 Kod
Telefon: - Potatif: - -
Telefon: - Bipe#:
Adres Imail:
Cheke isit si ou vie "The Children's Trust" mete non-w sou lis adres paran pou ka
resevwa infomasyon sou pwoblem ti moun ak la 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 vie "The Children's Trust" kontakte mwen pou pose'm kesyon
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