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MBKN Guardian Consent

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My Brother’s Keeper Newark – Guardian Enrollment










    - Surveys and/or interviews about my/their knowledge, attitudes, skills, and behaviors in regard to my/their academic development such as motivation to read; non-academic development such as leadership, mentorship, social action/advocacy and conflict resolution skills; and, overall satisfaction with the MBK program and other information related to my/their service as a MBK member, volunteer, participant, intern. I understand that the purposes of these surveys and interviews are to document the impact of the MBK Program on its participants, and to identify areas for improvement. I also understand that this information will remain private, and will only be accessed by my program director, site coordinator(s) and research assistants approved by MBKN.

    - I also understand that my/their responses will be used for program research and that I/they will not be individually linked to my responses.

    - I also hereby give MBK, its successors and assignees, irrevocable right to publish my name/child's name as well as any information shared by me/child with MBK in personal interviews about myself. I further give MBK, its successors and assignees, irrevocable right to use my voice recording and any recording, picture, portrait or photograph of myself in all forms and in all media and in all manner, without restrictions as to changes or alternations for advertising, promotion, exhibition or any other lawful purpose. I waive any right in inspect or approve any such photograph or recording. I agree that MBK owns the copyright in these photographs and recordings and I hereby waive any claims I may have based on any usage of any photograph, recording, or work derived there from. I have legal authority to execute this release, and I read and fully understand its concerns.

    I hereby certify that the statements in this application are correct and true. I understand that my/my child's involvement is based, in part, on the information provided within this application and my agreeing to terms as outlined in writing by MBK.


Mom and Son Enroll

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