Consent to Participate and Photo Release - Hatchlings, In the Nest

Mother Goose on the Loose, Hatchlings: In the Nest

Pilot Program

You are being invited to participate in the pilot of a new program: Mother Goose on the Loose, Hatchlings: In the Nest! The Hatchlings: In the Nest program is for families with newborns. It is based on the award-winning early literacy Mother Goose on the Loose program for children from birth to age 3 with their parents or caregivers https://mgol.net/.

The purpose of the Hatchlings program is to increase awareness in early literacy skills, the importance of reading, and child development milestones. These programs will be fun and interactive to model bonding around early literacy activities. Families will be given materials, in the form of books and educational toys, to keep and use at home. Parents will be asked to complete program evaluation surveys and may receive a follow-up phone call.

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* 1. Privacy and Confidentiality

All survey responses and data collected will be kept confidential. Participants will not be identified by name in any publication or presentation, unless they want their name published and grant permission.

I grant permission to use my name.

I do not grant permission to use my name.

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* 2. Permission to Use Photograph / Video

Photographs / videos of participants will be taken during the Mother Goose on the Loose Hatchlings program. With your permission, these photos and video clips may be shared with project partners, at conferences, on websites, and for publications, such as, Maryland State Library, American Library Association, Mother Goose on the Loose website, and Children & Libraries magazine and may be used for any lawful purpose including publicity, illustration, advertising, and Web content.

I grant permission to use my photographs and video (with my name included).

I grant permission to use photographs and video (without my name included).

I do not grant permission to use photographs and video with my image.

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* 3. I have read and understand all of the above.

Yes

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* 4. Name

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* 5. Address

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* 6. Email (If you do not use email, please write, none, in the space below.)

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* 7. Phone

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* 8. Date

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* 9. County

Calvert County

Caroline County

Carroll County

Cecil County

Harford County

Howard County

Kent County

Montgomery County

Prince George's County

Queen Anne's County

Wicomico County

Consent to Participate and Photo Release - Hatchlings, In the Nest

Mother Goose on the Loose, Hatchlings: In the NestPilot Program

Question Title

* 1. Privacy and ConfidentialityAll survey responses and data collected will be kept confidential. Participants will not be identified by name in any publication or presentation, unless they want their name published and grant permission.

Question Title

Question Title

* 3. I have read and understand all of the above.

Question Title

* 4. Name

Question Title

* 5. Address

Question Title

* 6. Email (If you do not use email, please write, none, in the space below.)

Question Title

* 7. Phone

Question Title

* 8. Date

Question Title

* 9. County

Mother Goose on the Loose, Hatchlings: In the Nest

Pilot Program

* 1. Privacy and Confidentiality

All survey responses and data collected will be kept confidential. Participants will not be identified by name in any publication or presentation, unless they want their name published and grant permission.