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Consent to Participate (Sample)

Early Childhood Nutrition Project

What is the Early Childhood Nutrition Project?

This project will provide additional information, resources, and support to families who have a child or children who are not eating as well as they need to for good health. A VNA social worker with special skills in feeding children and extensive knowledge of available resources, called a Nutrition Resource Coordinator, will work with the 20 families participating in this project. The Nutrition Resource Coordinator will meet with the principal caretaker of the child/children in their home, about once a week. At these meetings, the Nutrition Resource Coordinator will assist with getting any available benefits, make appropriate referrals to programs, and assist the family with any difficulties they are having that are affecting the availability of nutritious food or impacting the child/children’s health. Participants will also be invited to participate in cooking classes and will have access to emergency food, if needed. No participants will be excluded from this project because of their gender or being a member of a minority.

Families that participate will also meet with the WIC nutritionist every 3 months for additional nutrition information and weight checks to see if the child is improving in their growth. To measure if this project has been helpful in increasing nutrition knowledge and access to food resources, there will be a quiz on nutrition knowledge and some questions about availability of food in the household.

What is the purpose of this project?

This project provides assistance to the families of children that are either not gaining enough weight or gaining too much weight for their height because of problems with nutrition. This project, through the information provided by families, will help those administering food programs in Vermont do a better job of making those programs and services available. If this project is able to help families improve their children’s nutrition, then we hope to continue the program to help more families all over Vermont.

Are there any benefits to participating in this project?

The benefits to participating will be assistance with access to federal and local nutrition and food resources, additional nutrition education, closer monitoring of child’s growth, cooking and budgeting classes, and additional emergency food.

How long will the project last?

Your involvement with this project could last up to one year or could be shorter if your child/children’s growth normalized and you did not need the services any longer.

Can I begin to participate and then chose to drop out?

Yes. You can drop out of the project any time by calling Toki Eley at the VNA at (802) 860-4425. This decision not to participate will not affect your services from either the VNA or WIC.


The information you share with either the Nutrition Resource Coordinator or the WIC nutritionist will be confidential; any information shared outside of WIC or VNA will be combined with information from the other participants and will not have your name or any other identifiable information attached to it. You can request specific information to be shared, for example, with the pediatrician or to apply for benefits, etc.

While we will keep the information that you share with the Project staff confidential, we are required to comply with the law regarding certain types of information. For example, if you give us information about a minor or incapacitated adult that was in danger or was being abused/neglected, we may have to report this information to the appropriate individuals. Information we have may also be collected through legal process or court order.

Participants should keep pages 1&2 for future reference.


Consent to Participate

Early Childhood Nutrition Project

I, _____________, born on this date ___________, consent to participate in the Early Childhood Nutrition Project. I have read and understand the above information. I understand that I will be working with the Nutrition Resource Coordinator from the VNA and the WIC nutritionist, sometimes in my home, to assist me and my family with food resources, nutrition education, and access to programs in order to improve the nutritional well being of my family. As part of this project I agree to discuss with the Nutrition Resource Coordinator my present circumstances with regard to participation in programs, resources available, and issues that may affect health and nutrition in my family. I understand that these meetings will occur up to 4 times a month unless I request additional assistance and each meeting will take no more than an hour of my time.

I agree to appointments with the WIC nutritionist every 3 months for weight checks for my child/children and nutrition education. I will also complete a pre- and post- test on nutrition knowledge and provide information on changes in nutritional well-being of my family.

I agree to have the family nutrition plan shared with my child’s pediatrician, so he/she knows I am participating in this project.

I understand that the Project involves research intended to improve the nutritional health of my family by giving me information about food, nutrition, and available food resources. I also understand that the Project will share its general conclusions with the Agency of Human Services and to health and nutrition assistance programs in order to improve the way assistance is provided to persons who use these programs.

I understand that I can contact Toki Eley at the VNA by calling 860-4425 for more general information, to explain my rights if I choose to participate, or to answer any questions I may have about the Project.

I understand that I may revoke this consent to participate in the Early Childhood Nutrition Project at any time by notifying Toki Eley of the VNA at (802) 860-4425. I also understand that I can choose not to participate and that this decision will not impact my services from the VNA or from WIC.

Signature_______________________________ Date_________________________

Printed name_____________________________________________________

Relationship to child, if other than parent___________________________________