PARCPROGRAM DESCRIPTION

Proud and Responsible Communities (PARC) is a federally grant funded teen pregnancy prevention program through the Office of Adolescent Health. As only one of 75 sites selected nationwide, teens in Iredell-Statesville Schools have the honor of participating in this unique opportunity FREE OF CHARGE. Through science-based comprehensive education and program activities, teens gain the knowledge, tools, and skills necessary to reduce their risk of pregnancy and sexually transmitted diseases (STDs).

Making Proud Choices CURRICULUM

PARC program participants receive the CDC identified evidence-based curriculum Making Proud Choices (MPC), which is delivered by trained health facilitators at various sites in IredellCounty. The fun and interactive MPC curriculum sessions include:

* Getting to Know You and Making Your Dreams Come True* The Consequences of Sex: HIV Infection

* Attitudes and Beliefs about HIV/AIDS and Condom Use*Strategies for Preventing HIV Infection

* The Consequences of Sex: STDs* The Consequences of Sex: Pregnancy

* Explanation of FDA Approved Contraception methods* Developing Condom Use Skills and Negotiation Skills

Students are taught that abstaining from sex is the best and safest choice for teens. They are also given the skills and resources necessary to stay healthy if they are sexually active. An important component of our approach is the strong emphasis on family and community. Materials are available for review at the parent’s request.

INCENTIVES

Students receive a $100 gift card for the successful completion of the program. They also receive gift cards for future follow-up surveys completed.Snacks and transportation to program sessions, field trips, and medical, dental, and reproductive health appointments are provided if requested.

EVALUATION

For program evaluation purposes, participants will complete self-administered knowledge and behavior student surveys before and after the program for up to 5 years (2015). These surveys are confidential and no one outside the program evaluation team will have access to the answers. To compensate them for their time, students are given their $100 gift card following completion of the after-program survey.

*permission for program participation expires 12/31/2015.

Please keep this sheet for your records.

Complete, sign, and return the following 2 forms to your child’s school or participating program site.

For additional information please contact:

Amanda Peters

phone: 704.832.2559 fax: 704.978-0078

Iredell-Statesville Schools ADR 410 Garfield Street Statesville, NC 28677

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STUDENT INFORMATION

Student Name: ______

(Nombre del Estudiante)

School/Center Name: ______Age:______ Grade: ______

(Nombre de la Escuela/Centro) (Edad) (Grado)

Parent/Guardian Name: ______

(Nombre de Padre de Familia)

Address where student resides:(Dirección donde vive el estudiante)

______

Street (domicilio) Apt. City(ciudad) State(estado) Zip(código postal)

Home/Cell Phone: ______Work Phone:

(Numero de teléfono de casa o celular) (Numero de teléfono de trabajo)

Emergency Contact Name:______Relationship to Student: ______

(Persona para contactar en una emergencia) (Relación al estudiante)

Emergency Phone Number:______

(Numero de teléfono en case de emergencia)

Details of known allergies to foods, drugs, insect bites, etc or medical conditions:(Indique alergias a comidas, medicamentos, insectos, etc. y otra información de condiciones médicas o situaciones en la que debemos saber)

______

Does your child need transportation home from program sessions? YesNoUnsure

¿Necesita su hijo transporte a casa del programa? SiNoNo se

Circle days child is available to participate after school:FALL (Aug.-Dec.):Mon.Tues. Wed. Thurs. Fri.

Marque los días que puede participar después de la escuelaagosto-diciembre:Lun. Mar. Mier. Juev. Vier.

SPRING (Jan.-May):Mon.Tues. Wed. Thurs. Fri.

Enero-mayo:Lun. Mar. Mier. Juev. Vier

SUMMER (Jun.-July):Yes No

Junio-julio:SiNo

SATURDAYS (Any):YesNo

Sábados:SiNo

Student Name: ______

Initial byALL the program activities for which you give permission:

___ YES;my child may participate in PARC program activities as described above.

___ YES; my child may be transported by PARC program staff in authorized school vehicles to and from program sessions, field trips, and medical, dental, and reproductive health appointments if requested.

___ NO; I DO NOT give my child permission to participate in PARC program activities.

I have read and understand the requirements for PARC program participation as described on page 1.My signature and initials for permission indicate that I accept the policies and authorize the releases indicated below:

  • All PARC partners and employees will exercise reasonable judgment and care in planning and operating program trips and activities.
  • I understand and agree that PARC employees and partners will not be held liable for injuries resulting from accidents or unanticipated occurrences, including damage or theft of property.
  • I hold harmless and indemnify all PARC partners, agents, employees, volunteers, and contractors from any and all claims, demands, and causes of action that arise resulting from my child’s participation in PARC, including during the provision of transportation services.
  • Students must follow the host school or center’s code of conduct and rules.
  • I authorize PARC personnel to seek emergency medical care for my child in the event of a medical emergency.
  • I consent PARC evaluation staff to obtain pre- and post- student surveys for program evaluation purposes.

______

Parent/Guardian Signature Today’s DatePhone Number

Return to School/Center Staff or

Amanda Peters

phone: 704.832.2559 fax: 704.978.0078

Iredell-Statesville Schools ADR 410 Garfield Street Statesville, NC 28677

**THIS FORM MUST BE SIGNED AND RETURNED TO PARTICIPATE**

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