Field Methods: Teens: January 2008

Thursday, January 31, 2008

Consent: The Last Word?

Here's something to read over the next week. Professor Hartman replied to my question about adolescent participation in research. She agrees with me that the issue is murky, but when in doubt err on the side of "yes" (try and get parent and adolescent informed consent). At least have the informant speak to his/her parent, explain the project, and go from there.
The risks are minimal, and you are not professional researchers, and are engaged in classroom exercises. Nevertheless...let's try and educate parents as well as informants, and really explain the nature of class to them---and above all try and get consent from both parties.
Let me know what happens.
Below is the URL of a long article (2006, Vol. 4, Issue 1) by Professor Hartman on this issue:
http://www.rutgerspolicyjournal.org/

Tuesday, January 29, 2008

Consent: The Tuskegee Study Scandal

Some of you may want to read further on this notorious case of "non-informed consent." It is a very sad chapter in our history:
http://www.npr.org/programs/morning/features/2002/jul/tuskegee/

This is a link to National Public Radio's story on the "Tuskegee Experiments": it begins with,

July 25, 2002 --Thirty years ago today, the Washington Evening Star newspaper ran this headline on its front page: "Syphilis Patients Died Untreated." With those words, one of America's most notorious medical studies, the Tuskegee Syphilis Study, became public.

"For 40 years, the U.S. Public Health Service has conducted a study in which human guinea pigs, not given proper treatment, have died of syphilis and its side effects," Associated Press reporter Jean Heller wrote on July 25, 1972. "The study was conducted to determine from autopsies what the disease does to the human body."

Consent Forms (2)

Department of Health and Human Services
Office for Protection from Research Risks
Part B
TIPS ON INFORMED CONSENT
The process of obtaining informed consent must comply with the requirements of
45 CFR 46.116
. The documentation of informed consent must comply with
45 CFR 46.117.
The following comments may help in the
development of an approach and proposed language by investigators for obtaining consent and its approval by IRBs:
•
Informed consent is a process, not just a form. Information must be presented to enable persons tovoluntarily decide whether or not to participate as a research participant. It is a fundamental mechanismto ensure respect for persons through provision of thoughtful consent for a voluntary act. The procedures used in obtaining informed consent should be designed to educate the subject population interms that they can understand. Therefore, informed consent language and its documentation (especiallyexplanation of the study's purpose, duration, experimental procedures, alternatives, risks, and benefits) must be written in "lay language", (i.e. understandable to the people being asked to participate). Thewritten presentation of information is used to document the basis for consent and for the participants'future reference. The consent document should be revised when deficiencies are noted or when additional information will improve the consent process.
•
Use of the first person (e.g., "I understand that ... ") can be interpreted as suggestive, may be relied upon as a substitute for sufficient factual information, and can constitute coercive influence over a subject.
Use of scientific jargon and legalese is not appropriate. Think of the document primarily as a teaching tool not as a legal instrument.
•
Describe the overall experience that will be encountered. Explain the research activity, how it isexperimental (e.g., a new drug, extra tests, separate research records, or nonstandard means of management, such as flipping a coin for random assignment or other design issues). Inform the humanparticipants of the reasonably foreseeable harms, discomforts, inconvenience and risks that are associated with the research activity. If additional risks are identified during the course of the research,the consent process and documentation will require revisions to inform participants as they are recontacted or newly contacted.
•
Describe the benefits that participants may reasonably expect to encounter. There may be none other than a sense of helping the public at large. If payment is given to defray the incurred expense for participation, it must not be coercive in amount or method of distribution.
•
Describe any alternatives to participating in the research project. For example, in drug studies the medications) may be available through their family doctor or clinic without the need to volunteer for the research activity.
•
The regulations insist that the participants be told the extent to which their personally identifiable private information will be held in confidence. For example, some studies require disclosure of information to other parties. Some studies inherently are in need of a Certificate of Confidentiality which protects the investigator from involuntary release (e.g.,subpoena) of the names or other identifying characteristics of research participants. The IRB will determine the level of adequate
9
/human subjects/guidance/ documents
http://ohrp.osophs.dhhs.gov/humansubjects/guidance/icfips.htm
requirements for confidentiality in light of its mandate to ensure minimization of risk and determination that the residual risks warrant involvement of participants.
•
If research-related injury (i.e. physical, psychological, social, financial, or otherwise) is possible in research that is more than minimal risk (see 45 CFR 46.102[g]), an explanation must be given of
whatever voluntary compensation and treatment will be provided. Note that the regulations do not limit injury to "physical injury". This is a common misinterpretation.
•
The regulations prohibit waiving or appearing to waive any legal rights of participants. Therefore,for example, consent language must be carefully selected that deals with what the institution is voluntarily willing to do under circumstances, such as providing for compensation beyond the provisionof immediate or therapeutic intervention in response to a research-related injury. In short, participants should not be given the impression that they have agreed to and are without recourse to seek satisfactionbeyond the institution's voluntarily chosen limits.
•
The regulations provide for the identification of contact persons who would be knowledgeable to answer questions of participants about the research, rights as a research participants, and
research-related injuries. These three areas must be explicitly stated and addressed in the consent process and documentation. Furthermore, a single person is not likely to be appropriate to answer questions in all areas. This is because of potential conflicts of interest or the appearance of such.Questions about the research are frequently best answered by the investigator(s). However, questionsabout the rights of research participants or research-related injuries (where applicable) may best be referred to those not on the research team. These questions could be addressed to the IRB, an ombudsman, an ethics committee, or other informed administrative body. Therefore, each consentdocument can be expected to have at least two names with local telephone numbers for contacts toanswer questions in these specified areas.
•
The statement regarding voluntary participation and the right to withdraw at any time can betaken almost verbatim from the regulations (45 CFR 46.116[a][8]). It is important not to overlook the need to point out that no penalty or loss of benefits will occur as a result of both not participating or withdrawing at any time. It is equally important to alert potential participants to any foreseeable consequences to them should they unilaterally withdraw while dependent on some intervention tomaintain normal function.
documents -- http://ohrp.osophs.dhhs.gov/humansubjects/guidance/ictips.htm
•
Don't forget to ensure provision for appropriate additional requirements which concern consent. Some of these requirements can be found in sections 46.116(b), 46.205(a)(2), 46.207(b), 46.208(b), 46.209(d),46.305(a)(5-6), 46.408(c), and 46.409(b). The IRB may impose additional requirements that are not
specifically listed in the regulations to ensure that adequate information is presented in accordance with institutional policy and local law.
10
SAMPLE CONSENT FORM
You are invited to participate in a study of (state what is being studied.) We hope to learn (state what the study is designed to discover or establish.) You were selected as a possible participant in this study because (state why and how the subject was selected.)
If you decide to participate, the researcher and/or his or her associates will (describe the procedures to be followed, how long they will take and their frequency. Describe the discomforts and inconveniences reasonably to be expected. Estimate the total time required. Describe the risks and the benefits reasonably to be expected.)
(Describe appropriate alternative procedures that might be advantageous to the participants, if any.
Disclose any standard treatment that is being withheld.)
(If the participants will receive any compensation or any other benefits, describe the amount or nature.
If participants may incur costs because of participation, list them.)
Your decision whether or not to participate will not prejudice your future relations with the (name institution or agency). If you have any questions, please ask us. If you have any additional questions later (state of the name of the principal investigator and give a phone number or address,) will be happy to answer any of them.
Your signature indicates that you have read the information provided above and have decided to
participate. You may withdraw at any time without prejudice after signing this form should you
choose to discontinue participation in this study.
___________________________________________
___________________________
Signature Date
__________________________________________
___________________________
Signature of Parent or Legal Guardian
Date
(Signature of Parent or Guardian is not required for participants who consent for themselves.)
Message to Participants: Any information that is obtained in connection with this study and that can be identified with you will remain confidential and will be disclosed only with your permission. (If the researcher will be releasing information to anyone for any reason, state the persons or agencies to whom
the information will be furnished, the nature of the information to be furnished and the purpose of the disclosure.)
11

Monday, January 28, 2008

Consent Links

Student Classroom Exercises:
Primary Goal: to learn about and practice anthropological field methods
Informants: adolescent males/females/groups

Below are numerous links on ethics and informed consent when participating/oberserving/writing about human informants

Science/Biomedical Approaches
http://www.nsf.gov/bfa/dias/policy/hsfaqs.jsp
• National Science Foundation: “Frequently Asked Questions”: Interpreting the Common Rule for the Protection of Human Subjects for Behavioral and Social Science Research

EXEMPTIONS (NSF WEBSITE)

What exemptions of the Common Rule are most appropriate to social science research?

The Common Rule states that there are 6 categories of research that are exempt (from full IRB review). The first 4 of the exemptions will be most appropriate for social science research:

Research in educational settings involving educational practices. (§ 101 (b) (1))
Research involving educational tests (cognitive, diagnostic, aptitude, achievement), surveys, interviews, or observations of public behavior, unless subjects are identified and disclosure of responses would involve more than reasonable risk. (§ 101 (b) (2))
Research involving educational tests (cognitive, diagnostic, aptitude, achievement), surveys, interviews, or observations of public behavior not exempt under preceding exemption if human subjects are elected public officials, and if federal statutes require confidentiality of identifiable information. ((§ 101 (b) (3))
Research involving the collection or study of existing data if publicly available or unidentifiable. ((§ 101 (b) (4))
Research and demonstration projects designed to study public benefit or service programs. ((§ 101 (b) (5))
Taste and food quality evaluation and consumer acceptance studies. ((§ 101 (b) (6))

Exempt research is free from continued oversight by the IRB although the institution (either a designated IRB representative, the entire committee, or some other institutional authority), not the researcher, must determine that the project is exempt in the first place. Usually this is accomplished through a brief review process.

Does this mean that all questionnaire, educational test, and interview-based studies are exempt?

Such studies are exempt UNLESS:

Specific individual human subjects can be identified directly or through identifiers linked to them (i.e., their names, telephone numbers or other unique identifiers are recorded in the data)

AND disclosure of their responses could place them at risk of:

criminal/civil liability, or
damage to their financial standing, employability, or reputation

Research on vulnerable populations may not be exempt. Consult with your local IRB or NSF program officer for guidance in specific cases.

When the subjects are public officials or candidates for public office, the research is exempt even when identifiers are included or disclosure might be harmful.

When the subjects are public officials or candidates for public office, the research is exempt even when identifiers are included or disclosure might be harmful. However, all research should be bound by professional ethics and respect for respondents to guard their privacy whether or not the research is exempt (unless the participants understand that their information may be made public and permission is granted).

Classroom Exemptions (NSF Site):
Does research conducted as a classroom exercise count as human subjects research?
The Common Rule defines research as "a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge" (§ 102.d)
This includes activities, which are intended to lead to published results, or for example, findings presented at a professional meeting. Classroom exercises, involving interactions with human participants, which are part of an educational program, and are not designed to advance generalizable knowledge, are not covered by this regulation. Similarly, evaluations for quality improvement or assessment of instruction are not considered research so long as they are not designed to create generalizable knowledge.

How can research conducted as a classroom exercise be reviewed to protect human participants?
Since the Common Rule exempts classroom exercises (see above), the IRB has no mandated role to play in reviewing such exercises. However, the IRB typically is the only institutional store of expertise about human subjects protections, and may in principle be involved in such research in an oversight function. The following suggestions are offered as guidance for institutions seeking to protect participants from harm in such situations without overburdening IRBs with needless review responsibilities.
The relevant department should set up a Human Research Committee to review classroom exercises for harm to participants.
The department should state, in writing, what sort of research is reviewed in the department (i.e., classroom exercises, non federally-funded research, etc. ) in contrast to research which must go to the IRB.
The department should state, in writing, the criteria used to evaluate proposals (i.e., voluntary participation, informed consent, lack of risk of harm, lack of deception, procedures for ensuring confidentiality of data), and the mechanism used to perform the evaluation (i.e., a standing committee, an ad hoc committee appropriate to specific proposals, etc. )
The department should specify, in writing, the records it will keep. This may consist of the proposal itself, each reviewer's comments, correspondence with the researcher including requests for revisions and responses to requests. These records should be open for inspection at any time by the IRB or the designated institutional official. There should be at least one review per year.
It is a good idea for one member of the departmental committee to be a formal member of the IRB, to insure appropriate levels of communication between the department and the IRB, and training for the departmental committee.

Research v. Classroom Exercises

Activities that require IRB review are strictly limited to research; CFR 46.112 (d) defines research:
(d) Research means a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge. Activities, which meet this definition, constitute research for purposes of this policy, whether or not they are conducted or supported under a program, which is considered research for other purposes. For example, some demonstration and service programs may include research activities.

http://ori.hhs.gov/education/products/ucla/chapter2/default.htm
• This site, supported by the federal government, carefully lays out the issues of research with human subjects for medical researchers
o http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.htm
• The Federal “Common Rule”: informed consent
o http://www.hhs.gov/ohrp/irb/irb_chapter6.htm#g4
• Special cases within the “Common Rule” (including children and minors)

On-line Training Course: Research with Human Subjects:
U.S. Dep't of Health and Human Services
Health Resources and Service Administration
http://www.hrsa.gov/humansubjects/

American Anthropological Association Response to Federal Guidelines: Research with Human Subjects, and Institutional Review Boards (IRB)
http://www.aaanet.org/committees/ethics/ethcode.htm
• American Anthropological Association Code of Ethics
http://www.aaanet.org/stmts/irb.htm
• American Anthropological Association Statement on Ethnography and Institutional Review Boards
http://www.aaanet.org/ar/irb/humresethics2.htm
• Human Research Ethics: history/documents
http://www.aaanet.org/press/an/infocus/hrp/Plattner.htm
• Human Subjects Protection: Statement by Stuart Plattner

NSF Guidelines on Ethnographic Research

Is ethnography covered by the Common Rule?
Ethnography refers to a type of social science research where the researcher studies human behavior in a natural setting, rather than in a laboratory, for purposes of understanding the culture of that particular population. Research may involve observations and/or interviews with people in that setting. Since human participants are involved, the research is covered by the regulations.

Is ethnographic research exempt?
Depending on the specifics of the research project, ethnographic research may be exempt, qualify for expedited review, or require full IRB review. Although research involving public behavior is exempt under the Common Rule, projects focusing on sensitive information, where the disclosure of responses could harm the respondent, require full review.

How should research involving "snowball samples" be handled from a human subjects perspective?
In a "snowball sample" each respondent is asked to suggest other persons for inclusion in the research. These persons are then contacted to see if they wish to serve as research participants. This is a valid procedure often used by investigators who seek to recruit from populations for which adequate sample frames are not available. For example, a researcher seeking to study patterns of informal leadership in a community may ask individuals to name others who are influential in a community. Similarly, studies of the diffusion of ideas and acceptance of new technologies can be traced through scientific and medical communities.
Snowball samples in and of themselves do not necessarily pose a risk for human subjects. IRBs should follow the normal procedure of examining the project for risks of harm commensurate with normal life. Each respondent is given the opportunity to participate or to decline participation.
For studies studying sensitive topics, study protocols should adhere to the recommendations for confidentiality. For example, studies of networks of drug users or tracking sex partners of HIV+ cases require extreme caution with information gathered from one subject about another. All information should be treated confidentially. (See Certificate of Confidentiality)

Is written documentation of informed consent required in ethnographic research?
Ethnographic research interviews are not necessarily formal interviews with a questionnaire. They often are simple conversations on the respondent's home ground (as opposed to the researcher's laboratory). Competent adult individuals have the option of participating and responding to questions or the respondent has the choice of not allowing the researcher access to his or her person, ignoring requests for information, giving misleading replies, or responding to requests in other ways that preserve the respondent's dignity and independence. Informed consent is usually implied by the respondent's willingness to talk to the researcher.
In most ethnographic projects a request for a written, formal consent would seem suspicious, inappropriate, rude and perhaps even threatening. In other words, written consent can potentially harm the research interaction and generate rather than ameliorate concern in respondents. In many parts of the world, for many people with a history of exploitation and unfair dealings with authorities and government, a request to sign a form is fraught with danger. Respondents may not be fully literate, may not have familiarity or experience with social science research, and may have learned to expect the worst from strangers through experience or popular belief.
The roles of women and minors are not necessarily the same in other societies as in the US. In many cultures women and children are forbidden from making any agreement without their husband's or father's permission, which may not be appropriate in all situations. Written informed consent in such cases would be impossible to obtain, or if obtained would generate concern in respondents.
Researchers should be sensitive to such cultural differences within the US as well as in cultures outside the US. A vital aspect of protecting and respecting human subjects is to "do your homework" of learning about the cultural norms of those you wish to study. Expertise regarding the locale is essential and may be provided by the investigator or a consultant. In these circumstances the Common Rule authorizes a waiver of written documentation. § 117 (c) (1) discusses situations where the only record linking the subject and the research would be the consent document, and the principal risk would be potential harm resulting from a breach of confidentiality.
§ 117 (c) (2) deals with waiving written documentation of informed consent in situations where "the research presents no more than minimal risk of harm to subjects and involves no procedures for which written consent is normally required outside of the research context." This covers a large portion of ethnographic research on non-sensitive topics.

How should IRBs proceed in reviewing ethnographic research?
As with any project, the IRB administrator should assess the research to determine if there is any risk of harm to participants (beyond that which might be experienced in daily life), to determine whether the research is exempt or qualifies for expedited or full review.

What is "group consent" and how is it relevant to informed consent?
The concept of informed consent derives moral force as a mark of respect for persons. The request for informed consent envisions each human being as autonomous and capable of making informed judgments about appropriate personal activities.
Many traditional societies rely on an elder or group of leaders to express decisions with respect to the group. An individual community member who acted independently, without the knowledge and consent of the group, might be seen as suspicious, perhaps acting counter to the best interests of everyone. The appropriate way for a foreigner to get permission to do research in a setting like this would be to present the project in an open meeting, allowing questions to be raised and answered publicly. After formal group approval, any individual member of society would be free to cooperate or not with the research project.
In all societies, when research is planned in sharply defined communities, consultation with community representatives may be necessary in order to avoid negative gossip and refusals to participate. Such community consultation and public relations is part of a good research design and not a substitute for individual informed consent.

Richard Stockton Application To Undertake Research With Human Subjects (from Stockton's IRB)
http://intraweb.stockton.edu/eyos/grantsoffice/content/docs/IRB%20Application%20Fillable%20modified%20040207.pdf

Exemptions to Federal Regulations (to be reviewed by the Stockton IRB)
Appendix A
CODE OF FEDERAL REGULATIONS
TITLE 45: PUBLIC WELFARE
PART 46: PROTECTION OF HUMAN SUBJECTS
EXEMPT ACTIVITIES
Paragraph 46.101
(b) Unless otherwise required by Department or Agency heads, research activities in which he only involvement of human subjects will be in one or more of the following categories are exempt from this policy:
(1) Research conducted in established or commonly accepted educational settings, involving normal education practices,such as (i) research on regular and special education instructional strategies, or (ii) research on the effectiveness of or the comparison among instructional techniques, curricula, or classroom management methods, unless (a) information obtained is recorded in such a manner that human subjects can be identified, directly or through identifiers linked to the subjects; and (b)any disclosure of the human subjects' responses outside the research could reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects' financial standing, employability, or reputation
(2) Research involving the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures,interview procedures or observation of public behavior, unless: (please see a and b above)
(3) Research involving the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures,interview procedures or observation of public behavior that is not exempt under paragraph (b)(2) of this section, if: (i) the human subjects are elected or appointed public officials or candidates for public office, or (ii) Federal statute(s) require(s)without exception that the confidentiality of the personally identifiable information will be maintained throughout the
research and thereafter.
(4) Research involving the collection or study of existing data. documents, records, pathological specimens, or diagnostic specimens, if these sources are publicly available or if the information is recorded by the investigator in such a manner that subjects cannot be identified, directly or through identifiers linked to the subjects.
(5) Research and demonstration projects which are conducted by or subject to the approval of the Department or Agency heads, and which are designed to study, evaluate, or otherwise examine:
(i) Public benefit or service programs; (ii) procedures for obtaining benefits or services under those programs; (iii) possible changes in or alternatives to those programs or procedures; or (iv) possible changes in methods or levels of payment for benefits or services under those programs.
(6) Taste and food quality evaluation and consumer acceptance studies, (i) if wholesome foods without additives are consumed or (ii) if a food is consumed that contains a food ingredient at or below the level and for a use found to be safe, or agricultural chemical or environmental contaminant at or below the level found to be safe, by the Food and Drug Administration or approved by the Environmental Protection Agency or the Food Safety and Inspection Service of the U.S.Department of Agriculture.
Source: 63FR 60364-60367, November 9, 1998. Department of Health and Human Services.

Consent Forms (1)

Here are two from a student who took my field methods class last year, but is now working on an independent study with me about adolescent culture as well (what do you think?)

Participant Form
The Richard Stockton College of New Jersey
Department of Anthropology
Informed Consent
Description and Purpose of the Research

___________________________ is conducting research to fulfill requirements for a college course titled _________________________________________________.
This research consists mainly of ethnographic fieldwork, which involves observations and interviews, as well as interpretation and analysis of information gathered from these activities. Ethnography is a kind of research commonly done by scholars in social science fields such as Anthropology. The general purpose of this ethnographic research is to learn how a group of adolescents makes sense of their own community and relationships with each other, as well as their surrounding communities and schools.
For this study I will be creating an ethnographic web page through MySpace for the use of those who wish to participate in this project. All privacy settings will be on and content will be seen only by me, the other group members, and my professor. The MySpace page is intended to be a creative/educational, format/content collaboration between me and the group participants, with the intent of the participants being co-authors of the page. This research will be used for individual presentation and only read by the professor.

Participant’s Agreement:

I am aware that my participation in this project is voluntary. If, for any reason, at any time, I wish to stop the interview or leave the group, I may do so without having to give an explanation. I understand the intent and purpose of this research. The researcher has reviewed the individual and social benefits and risks of this project.
I am aware that the data will be used for a paper and presentation. I have the right to review, comment on, and/or withdraw information prior to the paper’s submission and presentation. The data in this study are confidential and anonymous with respect to my personal identity unless I specify/indicate otherwise.

I grant permission for the use of this information for a [participant to initial permission]
____________ Paper ____________ Presentation

I do______/do not_______wish that my identity be kept confidential.

I have read the above form, and, with the understanding that I can withdraw at anytime, and for whatever reason, I consent to participate in this project.

____________________________ ____________
Participant’s signature Date

_____________________________________
Print Name

Contact Information:
If you have any questions, concerns, or complaints about this research project, please contact my advisor, Joseph Rubenstein, Professor of Anthropology. Joe.Rubenstein@Stockton.edu

Parental Form
Description and Purpose of the Research

___________________________ is conducting research to fulfill requirements for a college course titled _________________________________________________.
This research consists mainly of ethnographic fieldwork, which involves observations and interviews, as well as interpretation and analysis of information gathered from these activities. Ethnography is a kind of research commonly done by scholars in social science fields such as Anthropology. The general purpose of this ethnographic research is to learn how a group of adolescents makes sense of their own community and relationships with each other, as well as their surrounding communities and schools.
For this study I will be creating an ethnographic web page through MySpace for the use of those who wish to participate in this project. All privacy settings will be on and content will be seen only by me, the other group members, and my professor. The MySpace page is intended to be a creative/educational, format/content collaboration between me and the group participants, with the intent of the participants being co-authors of the page. This research will be used for individual presentation and only read by the professor.

Parental Consent:

I am aware that my teenager is participating in this project, and that participation is voluntary. If, for any reason, at any time, I wish for my teenager to stop the interview or leave the group, I may have him/her do so without having to give an explanation. I understand the intent and purpose of this research. The researcher has reviewed the individual and social benefits and risks of this project.
I am aware that the data will be used for a paper and presentation. I understand that my teenager will be using MySpace, and that no one outside of the group will be able to view the website. I am aware that all content posted by participants is confidential and will be monitored. I will respect my teenager’s privacy in regards to this project, and understand that if any information is posted by my teenager that causes alarm to the researcher I will be contacted immediately. I have the right to request information about this project at any time. The data in this study are confidential and anonymous with respect to my teenager’s personal identity unless he/she specifies or indicates otherwise.
I have read the above form, and, with the understanding that I can contact the researcher with questions or withdraw my teenager from this project at anytime, and for whatever reason, I grant my teenager permission to participate in this project.

____________________________¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬________
Participant’s Name

_____________________________________ ____________
Parent’s Signature Date

Contact Information:
Gina Roseboro
gina.roseboro@gmail.com
856-981-4428