Hayward Promise Neighborhood

Consent Agreement for Data Disclosure and Sharing

By signing this agreement, you give your consent to disclose and share personally identifiable information of the persons listed on page 2 of this form, with authorized partners in Hayward Promise Neighborhoods (HPNs).
The programs and services of HPNs are designed to guide your children and families from cradleto college-to-career and to provide strong systems of family and community support.

The purpose of sharing your personally identifiable information among the authorized partners of HPNs is to ensure that services are well coordinated and aligned, and to conduct ongoing evaluation of the impact and of the impact and improvement of our programs.

The personally identifiable information to be disclosed and shared with the partners of HPNs listed below may include, but is not limited to:

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

HPNs 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 Personal information will not be published in a manner that will lead to the identification of any individual.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 and 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

California State University East Bay
Eden Area Regional Occupation Program
Hayward Unified School District
Eden Youth and Family Center
Chabot College
City of Hayward
La Familia Counseling Service
Community Child Care Council of Alameda County
Tiburcio Vasquez Health Center
Alameda County Public Health Nursing
EigenX (Case Management System Maintenance only)

Furthermore, I consent that the following entities may obtain the information described above stripped of any and all direct identifiers (name and contact information deleted):
U.S. Department of Education and its authorized contractor(s).

No health care provider, including without limitation Tiburcio Vasquez Health Center, will share any protected health information with authorized partners of HPNs based on this consent agreement.
This agreement constitutes the granting of consent for disclosure of protected education information under the Family Educational Rights and Privacy Act (FERPA) to entities and authorized partners of HPNs.

This consent agreement releases all Hayward Promise Neighborhoods and authorized partners and their respective 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, HPNs Principal Investigator, 510-885-3942 carolyn.nelson@csueastbay.edu

Edgar Chavez, HPNs Executive Director, 510-885-3994 edgar.chavez@csueastbay.edu

Mariana Triviso, Hayward Unified School District HPN Coordinator, 510-723-3857 x34160
mtriviso@husd.k12.ca.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

Child's First & Last Name

DOB:

Student ID

Child's First & Last Name

DOB:

Student ID

Child's First & Last Name

DOB:

Student ID

B. PARENT/GUARDIAN AND ADULTS 18 YEARS OR OLDER

First & Last Name

DOB:

Student ID

C. DECLINE CONSENT TO SHARE PERSONALLY IDENTIFIABLE INFORMATION:

First & Last Name

DOB:

Student ID