Hayward Promise Neighborhood

Consent Agreement for Data Disclosure and Sharing

By signing this agreement, you consent to disclose and share personally identifiable information of the persons listed in Section 2 of this form with authorized partners in Hayward Promise Neighborhoods (HPN) led by California State University, East Bay (See Table 1). Hayward Promise Neighborhoods (HPN) programs and services are designed to guide your children and families from cradle-to-college-to-career and provide strong family and community support systems. For more information about HPN, visit www.haywardpromise.org.

The purpose of sharing your personally identifiable information among the authorized partners of Hayward Promise Neighborhoods (HPN) is to: (a) ensure that services are well coordinated and aligned, (b) conduct ongoing evaluation of the impact and improvement of our programs, and (c) connect participants with services and resources.

The personally identifiable information to be disclosed and shared with the partners of Hayward Promise Neighborhoods (HPN) listed below may include but is not limited to:

Name, address, and date of birth, English learner/socioeconomic status
Program participation data (such as services received and attendance dates)
Program results and assessments (such as tests results)
School grades, performance reports, transcripts, and attendance.

Hayward Promise Neighborhoods (HPN) will make every effort to protect your personal information from unauthorized use or disclosure. Personal information will not be published in a manner that will lead to the identification of any individual. Your information will only be used for service provision and program evaluation purposes. No identifiable information will be disclosed to third parties not covered by this consent agreement without your prior written consent.

Hayward Promise Neighborhoods Authorized Partners

Alameda County Public Health Department
California State University, East Bay (CSUEB)
Chabot College
City of Hayward
4Cs of Alameda County
Deputy Sheriffs’ Activities League (DSAL)
Eden Area Regional Occupation Program (Eden ROP)

Eden Youth and Family Center (EYFC)
EigenX, LLC (for case-management system maintenance only)
Hayward Unified School District (HUSD)
Hayward Area Recreation and Parks District (HARD)
HTA Consulting
La Familia Counseling Service
Tiburcio Vasquez Health Center (TVHC)

Furthermore, you consent that the following party may obtain the information described above with any and all direct identifiers (individual’s name and contact information will be deleted before sharing): the U.S. Department of Education and its authorized contractor(s).

No health and mental health care provider, including and without limitation, Tiburcio Vasquez Health Center, La Familia Counseling Service, Alameda County Public Health Department, and CSUEB, will share any protected health information with authorized partners of HPN based on this consent agreement.

This agreement constitutes the granting of consent for the disclosure of protected education information under the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA) to entities and authorized partners of the Hayward Promise Neighborhoods (HPN) initiative at California State University, East Bay.

This consent agreement releases all Hayward Promise Neighborhoods (HPN) entities and authorized partners and their officers, agents, Board of Supervisors, and employees from any and all liability connected with the use or disclosure of your personally identifiable information.

For additional information please view our website www.haywardpromise.org and/or contact:

Carolyn Nelson, HPN Principal Investigator, carolyn.nelson@csueastbay.edu

Edgar Chávez, HPN Executive Director, 510-885-3994, edgar.chavez@csueastbay.edu

Mariana Triviso, HUSD-HPN Coordinator, 510-723-3857 ext. 34160, mtriviso@husd.us

Choose an option for Data Sharing Consent

A. PARENT/GUARDIAN FOR CHILD/CHILDREN UNDER 18 YEARS OLD

I, Parent's First & Last Name

Child's First & Last Name

DOB:

Student ID

1st Child's School

Child's First & Last Name

DOB:

Student ID

2nd Child's School

Child's First & Last Name

DOB:

Student ID

3rd Child's School

Child's First & Last Name

DOB:

Student ID

4th Child's School

B. PARENT/GUARDIAN OR STUDENTS 18 YEARS OR OLDER

First & Last Name

DOB:

Student ID

C. DECLINE CONSENT TO SHARE PERSONALLY IDENTIFIABLE INFORMATION:

First & Last Name

DOB:

Student ID