GOVERNMENT OF THE DISTRICT OF COLUMBIA
DEPARTMENT OF EMPLOYMENT SERVICES
MURIEL BOWSER DR. UNIQUE MORRIS-HUGHES
MAYOR DIRECTOR
DOES OFFICE OF YOUTH PROGRAMS (OYP)
PARENT CONSENT FORM
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Applicant’s Full Name Applicant’s Last 4 of SSN
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Applicant Signature Date
I,___________________________________________________________________________________, certify that I am the parent/ guardian of the minor applicant whose name
appears above, and hereby give my consent for the minor to participate in youth employment programs administered by the
D.C. Department of Employment Services (DOES) Office of Youth Programs (OYP) which include the Marion S. Barry Summer
Youth Employment Program (SYEP); the Marion Barry Youth Leadership Institute ( MBYLI); the Year-Round In- School and
Out-of-School Programs; the High School Internship Program (HSIP); and the College Internship Program (CIP); from the date
on the bottom of this consent form until such time the minor is no longer eligible to participate in youth employment programs
or I revoke this consent in writing. I further certify that all of the information contained within the minor’s application is correct
and true and that by enrolling my child in any OYP programs I hereby give permission to DOES and its partner organizations to
photograph/interview my child. It is my understanding that this photograph/interview or portions may be used by DOES and
its partner organizations to describe, promote, and publicize its programs. I agree to participate in this project without financial
remuneration, and I understand that this releases DOES and its partner organizations from any future claims, as well as from any
liability, arising from the use of said photograph/interview. I understand that by signing this form and enrolling my child in programs
offered by OYP in accordance with the District of Columbia Official Code Division V, Title 32, Chapter 2, I consent to the release
of certain education records related to my child to DOES as of the date by my signature below for the purpose of verifying my
child’s eligibility for these programs. I understand that the specific education records to be released to DOES include my child’s
first name, last name, date of birth, address, enrollment status, grade level, and attendance data. I further understand that DOES
will use this information for no other purpose than verifying that my child is eligible for its programs and will safeguard it against
further disclosure. I further understand that I have a right to inspect, review and challenge any of my child’s education records
and that I may request a copy of the records to be released to DOES pursuant to this consent by contacting the registrar or other
responsible school official at my child’s school. Further, I understand that by enrolling my child in programs offered by DOES, I
consent to my child participating in an on-going independent evaluation of the effectiveness of these programs. Further, I understand
that DOES may contact my child’s school for up to two years after their participation to obtain certain education records showing
their progress, including my child’s enrollment status, grades, test scores, suspensions, and attendance data and that DOES may
survey or interview my child about its programs as part of this evaluation. I understand that any information collected will be
used solely to assess DOES programs and to track general group trends. Individual responses will not be made public and neither
my child’s name nor any identifiers will be used in any report. Further, I understand that participation in any DOES evaluation
activity is completely voluntary and my child may withdraw at any time with no consequences and may opt-out of participating
in the evaluation by emailing s[email protected]ov or by contacting DOES via the contact information included on this form.
___________________________________________________________________________________________ ________________________________________________________ ______________________________________
Parent/Guardian Signature Relationship to Applicant Date
ATTENTION: Signed Parent Consent must be submitted to DOES Office of Youth Programs, via the Participant Youth Portal
or scanned to MBS[email protected]v. All applications for any programs offered by OYP will be considered INCOMPLETE
until this form is signed and submitted.
DO NOT WRITE BELOW THIS LINE
SIGNED PARENTAL CONSENT FORM RECEIVED BY:
__________________________________________________________________________________________________________________________________________________________________ ________________________________________
Staff Name (Printed) Staff Signature Date
