Consent/Opt-Out Form For Communities in Schools Program

Dear Sto-Rox Parent/Guardian:

Your school has become a Full-Service Community School! The Sto-Rox School District has partnered with Communities in Schools Pittsburgh Allegheny County (CISPAC) to implement this evidence-based school model. Full Service Community Schools (FSCS) provide educational opportunities and supports for students, their families, and community members to achieve school success. These results are achieved by leveraging the resources available in your community and making them accessible and available to your student, your family, and community members right in the school building. Over the next few years, you will notice an increase in the activities, services and supports offered at your student’s school.

The FSCS is funded in part by the US Department of Education, the Sto-Rox School District, and private donors and charitable foundations. Your School District’s Board has reviewed and approved CISPAC as our partner in this effort.

In order to evaluate the impact of the FSCS, Communities In Schools will need to keep track of every student’s involvement and participation in these activities. The school district is committed to preserving your student’s confidentiality, and as such, will only share your student’s name, grade level, and school ID number.

The Protection of Pupil Rights Amendment (PPRA), 20 U.S.C. § 1232h, requires the Sto-Rox School District to notify you and obtain consent or allow you to opt your child out of participating in certain school activities.

DOWNLOAD: CISPAC Consent/Opt-Out Form (DOCX)
DOWNLOAD: CISPAC Consent/Opt-Out Form (PDF)

If you do NOT want your student to participate in educational, enrichment or supportive activities through the Full Service Community Schools program, download the above form and (1) check the box marked “NO,” (2) sign the form and date it, and (3) return it to the school as soon as possible. If you have questions about this program or would like more information, please reach out to Monté Robinson, CISPAC’s Chief Program Officer, at (412) 361-4945.

Note: If you do not want your child to participate in Full Service Community Schools activities, please complete this form and return it to your student’s school. You do not need to return this form if you want your child to participate.