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After-School Initiative's Toolkit for Evaluating

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Child Assent to Participate in the [name of ASI program/agency] Program<br />

Evaluation<br />

As a participant in [name of ASI program/agency], I agree to be in a study to answer some questions about<br />

my activities, feelings and opinions about [name of ASI program] and how my participation has helped or<br />

not helped me. I understand that my answers are private [Choose either: (and that my name will not go on<br />

my answer sheet.) (OR) (and that my answers will only be reported as part of a bigger group and will not<br />

reflect my individual answers.)] I will not get a grade <strong>for</strong> my answers nor will anyone discuss my answers<br />

with me unless I ask them to. I agree to participate in this evaluation through May 2005 as long as I am<br />

participating in [name of ASI program/agency]. I can decide to stop being in this evaluation at any time<br />

without getting into trouble. If I do not answer the questions I will continue to be able to attend [name of<br />

ASI program].<br />

Child’s Name: (please print) _________________________________________________________<br />

Child’s Signature: _________________________________________________________________<br />

Date: ___________________________________________________________________________<br />

Date of Birth: ____________________________________________________________________<br />

Adult Witness*:______________________________________ Date: __________________________<br />

Adult Witness Signature: ______________________________________________________________<br />

*Witness must be present <strong>for</strong> the assent process.<br />

[Program copy OR Child Participant copy]<br />

<strong>Toolkit</strong> <strong>for</strong> <strong>Evaluating</strong> Positive Youth Development 45

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