LENA Consent Form

Forms

Required

Today's Daterequired
Must contain a date in M/D/YYYY format
Child's Namerequired
First Name
Last Name
Child's Genderrequired
Child's Clothing Sizerequired
0-3 months, 3-6 months, 6-12 months, 12-18 months, 18-24 months, 2T, 3T, 4T, 5T *Sizes run small*
Child's Date of Birthrequired
mm-dd-yy (Must contain a date in M/D/YYYY format)
Child's Age in Months
Child's Primary Addressrequired
Street, City, State, Zip Code
Parents Namerequired
First Name
Last Name
Relationship to childrequired
Preferred Languagerequired
Text Phone Numberrequired
Note: Texts are a key part of this program and will be sent to those numbers with the ‘Receive program texts’ checkbox checked. You’ll receive about three texts (primarily reminders) per week from 855-960-0731, and data and message rates may apply. If you are not or are no longer able to receive texts, please speak with your coordinator immediately. You can cancel your receipt of these text messages at any time by texting STOP to 855-960-0731. For help with these texts or with LENA Start, see your coordinator, or text HELP to 855-960-0731.
Receive program texts on this numberrequired
Primary Caregiver's Email Addressrequired
Secondary Caregiver's Name
First Name
Last Name
Relationship to child
Text Phone Number
Receive program texts on this number
Secondary Caregiver's Email Address
What is the child's mother's age?required
What is the highest degree obtained by the child's mother?required
What categories describe the child's mother? (Please mark all that apply)required
Does the enrolled child have any brothers or sisters? required
I am applying to attend LENA Start. I understand this includes using a small LENA recorder my child wears for a full day after each session, using special clothing. They cannot and will not be listened to and will be deleted after they are processed. My child and people around my child will be recorded during recording days.required
LENA Start is made up of 10 weekly sessions about 60 minutes long. If I am accepted and begin the program, I will attend sessions as scheduled, or arrange a makeup session if I have to miss a session. In order to graduate, I understand that I must: 1. Attend (or make up) all the first 4 sessions and at least 3 of the next 6 sessions 2. Turn in at least 6 LENA recordings required
Information that can be identified with me or my child will be kept confidential from anyone other than Mesquite ISD, LENA, and any affiliated professionals, all of whom will comply with all laws regarding confidentiality. I have read the note about texts above and agree that Mesquite ISD and LENA may use aggregated information for their own purposes in any way that does not reveal my or my child's identity or violate any federal, state, or local laws or regulations, and in accordance with LENA's privacy policy, available at lena.org/privacy-policy.required
The purpose of LENA Start is to improve child language development by teaching me practical techniques to increase personal interactions with my child. Specific improvements are not guaranteed. Instructors are not child development or healthcare professionals. If I have questions about my child’s health or development, I will consult a professional.required
If photos or videos taken during classes include me and/or members of my family, I give permission for use of these images by Mesquite ISD or LENA.required
LENA may provide the opportunity for me to complete ongoing language questionnaires until my child is 36 months of age. I agree to participate in this follow-up.required
By typing my name below, I apply to attend LENA Start program sessions. I have read and understood this form, my questions about LENA Start have been answered to my satisfaction, and I agree on behalf of myself and my child to the conditions. I and my child do not give up any of our legal rights as participants in LENA Start.required