ASPEN Parent Waiver

Parents and guardians must complete this Behavioral Health Screening Consent and Authorization Form (“Consent Form”) in order to allow your child/dependent (“Child”) to participate in the ASPEN Program.

By signing this Consent Form, you acknowledge and agree to the following:

ASPEN is a voluntary program, and you are free to decline participation on behalf of your Child.
If you consent for your Child to participate in the ASPEN Program, you give permission for your Child to receive mental and physical health screening and complete self-screening behavioral questionnaires related to mental health, which may include questions about depression, anxiety, thinking and behavior, the use of drugs and alcohol, and other related topics.
Your Child’s records will be kept confidential and will only be accessed by or disclosed when necessary to provide services or comply with the law. Specifically, your Child’s education records and/or health information collected for the ASPEN program could be disclosed to the following individuals and entities only when needed to provide services or when legally required:
- Authorized officials, counselors, social workers, staff, parents, and guardians for the purpose of providing ASPEN Program services.
- Specific personnel within ASPEN may have access to deidentified data as required, in adherence to ASPEN's Privacy Practices.
- To law enforcement officials, regulators, or other agencies and third parties only if required to comply with any legal or regulatory obligations.
- Crisis Counselors or professionals may have access if an emergency circumstance is identified such as suicidal or homicidal high risk.

Signature 1   I give permission and consent for my Child to participate in the ASPEN Program as described above.

Signature 2   I acknowledge and agree that records protected by the Health Insurance Portability and Accountability Act (“HIPAA”) will be used and disclosed in accordance with HIPAA and privacy practices of ASPEN Network Inc.

Signature 3   I acknowledge that I have received, read, and agreed to the ASPEN User Agreement and Terms of Use, and the school privacy practices available in the parent/guardian letter.

Signature 4   I understand that I may revoke this Consent Form upon providing written notice to info@aspennetworkinc.org. I further understand that until this revocation is made, this consent shall remain in effect and my educational/health-related records may be accessed, used, and disclosed for the specific purposes described above.

I do NOT give permission or consent for my Child to participate in the ASPEN program as described above.

Student Name*

First NameLast Name

Student School

Student Date of Birth*

Student District/School*

* Important: Please use the exact email address below that your student/child will use (or has already used) to register for ASPEN. This ensures that your signed waiver will be processed and matched up with their account. If the emails don’t match, the student will be unable to access ASPEN, and you will have to redo the waiver. Thank you for your attention to this detail.

Student/Participant Email*

example@example.com

Parent/Guardian Name*

First NameLast Name

Parent/Guardian Signature*

Date Signed*

Please verify that you are human*