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Consent and Referral forms
Not sure which program to select?
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to learn more about programs offered
Parent/Guardian Consent Form for See the Girl: In Elementary
Please enable JavaScript in your browser to complete this form.
Parent/Guardian Name
*
Girl's Full Name
*
I certify that I am the legal guardian of the above named girl.
*
Yes
No
School
*
Grade
*
Parent/Guardian Phone Number
*
Parent/Guardian Email
Girls Home Address
*
Girls Date of Birth
*
Girls Race
*
Black
White
Hispanic
Other
Girls Ethnicity
*
Non-Hispanic
Hispanic
Haitian
Jamaican
Grant or Deny Permission
I, the undersigned, do herby grant grant or deny permission to the Delores Barr Weaver Policy Center for the following:
Section 1
*
I grant permission to use my child’s image in the above mentioned capacities.
I deny permission to use my child’s image at all.
To use the image of my child, and Their grade and age, as marked by my selection below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, voice recording, and/or video taken of my child and/or family for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the Delores Barr Weaver Policy Center’s website: www.seethegirl.org.
Section 2
*
I grant permission to release my child’s information if eligible for additional services.
I deny permission to release information.
To release information about my child’s individual needs to a referral agency such as (Full ServiceSchools, Girl Scouts) if eligible to receive additional services and supports to increase her success. This may include your child’s name, date of birth, needs she is demonstrating, as well as your contact information.
Section 3
*
I grant permission to use my child’s information for research and reporting as described below.
I deny permission to use my child’s information for research and reporting as described below.
To provide reporting information to the Florida Department of Juvenile Justice Prevention Web system (JJIS) on the demographics and needs of girls served through the It’s Elementary program as per grant requirements. All information will be confidential.
Section 4
*
I grant permission to use my child’s information for research as described below.
I deny permission to use my child’s information for research as described below.
To access the school records of my child and allow use of the information for grant reporting purposes in order to provide information including number of absences and suspensions of all girls served to funders, such as the Department of Juvenile Justice. All information will be kept confidential.
Section 5
*
I grant permission to use my child’s information for research as described below.
I deny permission to use my child’s information for research as described below.
To learn and share more about the needs of girls and the impact of the Policy Center services by using girls’ individual statements in whole or in part. No personal data will be shared and all statements will be anonymous. This means no names or other identifying information will be used.
Date
*
I acknowledge that I understand and agree with the Youth Rights Policy and Rights and Grievance Procedure provided to me by the Delores Barr Weaver Policy Center.
Signature
*
Clear Signature
Website
Submit
Parent/Guardian Consent Form for See the Girl: In the Middle & Groups
Please enable JavaScript in your browser to complete this form.
Parent/Guardian Name
*
Girl's Full Name
*
I certify that I am the legal guardian of the above named girl.
*
Yes
No
School or after school program
*
Grade
*
Parent/Guardian Phone Number
*
Parent/Guardian Email
Girls Home Address
*
Girls Date of Birth
*
Girls Race
*
Black
White
Hispanic
Other
Girls Ethnicity
*
Hispanic
Non-Hispanic
Haitian
Jamaican
Grant or Deny Permission
I, the undersigned, do herby grant grant or deny permission to the Delores Barr Weaver Policy Center for the following:
Section 1
*
I grant permission to use my child’s image in the above mentioned capacities.
I deny permission to use my child’s image at all.
To use the image of my child, and Their grade and age, as marked by my selection below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, voice recording, and/or video taken of my child and/or family for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the Delores Barr Weaver Policy Center’s website: www.seethegirl.org.
Section 2
*
I grant permission to release my child’s information if eligible for additional services.
I deny permission to release information.
To release information about my child’s individual needs to a referral agency such as (Full ServiceSchools, Girl Scouts) if eligible to receive additional services and supports to increase her success. This may include your child’s name, date of birth, needs she is demonstrating, as well as your contact information.
Section 3
*
I grant permission to use my child’s information for research and reporting as described below.
I deny permission to use my child’s information for research and reporting as described below.
To provide reporting information to the Florida Department of Juvenile Justice Prevention Web system (JJIS) on the demographics and needs of girls served through the It’s Elementary program as per grant requirements. All information will be confidential.
Section 4
*
I grant permission to use my child’s information for research as described below.
I deny permission to use my child’s information for research as described below.
To access the school records of my child and allow use of the information for grant reporting purposes in order to provide information including number of absences and suspensions of all girls served to funders such as (the Department of Juvenile Justice). All information will be kept confidential.
Section 5
*
I grant permission to use my child’s information for research as described below.
I deny permission to use my child’s information for research as described below.
To learn and share more about the needs of girls and the impact of the Policy Center services by using girls’ individual statements in whole or in part. No personal data will be shared and all statements will be anonymous. This means no names or other identifying information will be used.
Date
*
I acknowledge that I understand and agree with the Youth Rights Policy and Rights and Grievance Procedure provided to me by the Delores Barr Weaver Policy Center.
Signature
*
Clear Signature
Comment
Submit
Referral Form for See the Girl: In the Community & Open Doors serving victims of sex trafficking
I am referring myself.
Click here to refer yourself
Please enable JavaScript in your browser to complete this form.
My First & Last Name
*
My Race
*
My Gender Identity
*
Date of birth
*
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Address
If referred person does not have stable housing, please list zip code or county of temporary residence.
County
*
Baker County
Clay County
Duval County
Nassau County
St. John County
Please select the county you live in.
Are you homeless or living in a shelter.
*
I am currently homeless
I live in a shelter
I have a history of homelessness
I do not have a history of homelessness
Contact Information
*
Parent/Guardian Name and Contact Information (if under 18)
Which program are you referring yourself to?
*
Open Doors – human trafficking involvement
Girl Matters In the Community
Not sure
Are you in need of? (check all that apply)
Legal Assistance
Transportation
Clothing
Housing
Food
Medical Needs
Other
Are you in involved in the Child Welfare System?
*
Yes, I am currently involved in the child welfare system
No, I am not currently involved, but I have a history of involvement in the past
I do NOT have a history of involvement in the child welfare system
Are you in involved in the Juvenile Justice, or Justice System?
*
Yes, I am currently involved in the justice system
No, I am not currently involved, but I have a history of involvement in the past
I do NOT have a history of involvement in the justice system
Substance Abuse History
*
Currently struggling with substance abuse
Has struggled with substance abuse in the past
Has never struggled with substance abuse in the past
Runaway
*
Has history of one runaway
Has history of more than one runaway
Does not have a history of runaway
Employment
*
Currently employed
Has previously been employed
Never been employed
School attendance
*
Attends school regularly
Does not attend school regularly
Is not enrolled
If you are currently enrolled in school, what school?
Last grade level completed, or current grade enrolled in.
*
Briefly describe the reason for seeking services with the Delores Barr Weaver Policy Center?
*
How did you hear about the Delores Barr Weaver Policy Center?
*
Today's Date
*
Phone
Submit
I am referring someone else.
Click here to refer someone else
Please enable JavaScript in your browser to complete this form.
Name of the person/agency making the referral
*
Your Phone Number
*
Your Email Address
*
All fields listed below are for the person you are referring.
Referred Person's Name
*
Referred Person's Race
*
Referred Person's Gender
*
Date of birth
*
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2
3
4
5
6
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8
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13
14
15
16
17
18
19
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21
22
23
24
25
26
27
28
29
30
31
/
YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Referred Person's Address
If referred person does not have stable housing, please list zip code or county of temporary residence.
County
*
Baker County
Clay County
Duval County
Nassau County
St. Johns County
Please select the county referred person lives in.
Which program is this person being referred to?
*
Open Doors – suspected human trafficking involvement
Girl Matters in the Community
Not sure
Is this person experiencing homelessness?
*
Currently experiencing homelessness
Currently living in a shelter
Has a history of homelessness
Does not have a history of homelessness
Referred Person's Contact Information
*
Parent/Guardian Name and Contact Information
*
Is this person in need of (choose ALL that apply)
*
Legal Assistance
Transportation
Clothing
Housing
Food
Medical Care
Other
Is this person involved with the Child Welfare System?
*
Yes, currently involved in the child welfare system
Not currently involved, but has a history of involvement in the past
Does NOT have a history of involvement in the child welfare system
Is this person involved with Juvenile Justice, or Justice System?
*
Yes, currently involved in the justice system
Not currently involved in the justice system
Does not have a history of involvement in the justice system
Substance Abuse History
*
Currently struggling with substance abuse
Has struggled with substance abuse in the past
Has never struggled with substance abuse in the past
Runaway
*
Has history of one runaway
Has history of more than one runaway
Does not have a history of runaway
Employment
*
Currently employed
Has previously been employed
Has never been employed
School Attendance
*
Attends school regularly
Does not attend regularly
Is not enrolled
If currently enrolled in school, what school?
Last grade level completed, or current grade enrolled in?
*
Any other community organization(s) involved with the person?
*
Briefly describe the reason for seeking services with the Delores Barr Weaver Policy Center?
*
How did you hear about the Delores Barr Weaver Policy Center?
*
Today's Date
*
Comment
Submit
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