<p> Lower Hudson Valley Perinatal Network Healthy From Birth For Life Consent Form</p><p>I, (name of youth participant) ______have been invited to be a Community Service Fellow of the Healthy From Birth For Life project, a social health marketing campaign of the Lower Hudson Valley Perinatal Network regarding community health beliefs on the topics of obesity and diabetes, and their relationship to birth outcomes. </p><p>I, (name of youth participant) ______understand that being a Fellow with Healthy From Birth For Life project will include (but is not limited to) my taking part in the following:  Community-based programming  Advisory meetings  Health education workshops  Community assessments (questionnaires, surveys, etc.)  Ongoing development of the social health marketing campaign</p><p>I, (name of youth participant) ______understand that as a Fellow of the Healthy From Birth For Life project during the Summer 2009 trimester, I am required to attend all weekly workshops and scheduled community events from June 2, 2009 to August 5, 2009, and that by doing so I ensure my eligibility to receive community service fellowship certification and a paid stipend. I understand that excessive absences (two or more) and/or tardiness may jeopardize my option to participate in this project and/or receive a full stipend. This commitment is to ensure the quality of both the community service that I deliver and the social health marketing campaign that I design and implement. If I attend and fully participate in the project, I will receive a paid stipend and community service experience in health education, marketing and human services.</p><p>I, (name of youth participant) ______understand that my participation in this project is voluntary and I have the right to stop participating at any time. However, I also understand that if I choose to discontinue participation before the completion of the Summer 2009 trimester, I forfeit my stipend and community service fellowship certification. There are no discomforts or risks associated with the project. Supervision and mentoring will be provided to me, as well as all participants, through the Lower Hudson Valley Perinatal Network.</p><p>I, (name of youth participant) ______understand that information from the project will be coded to ensure confidentiality and I will not be identified in any publication that may result in project, without signed consent. The workshops and community activities mentioned above will result in a social health marketing campaign called Healthy From Birth For Life, and will be presented in community settings. As a participant, my personal information (full name, birth date, complete address, etc.) will not be printed for public use.</p><p>95 Grasslands Road Valhalla, NY 10595 Phone: 914-493-6435 Website: www.LHVPN.net/HFBFL Fax: 914-493-1005</p><p>Lower Hudson Valley Perinatal Network organized in 2004 by the Maria Fareri Children’s Hospital Regional Perinatal Center with March of Dimes funding Lower Hudson Valley Perinatal Network Healthy From Birth For Life</p><p>I have been given a copy of this form, and understand that Michelle Gordon, project manager, will be available to answer further questions regarding any aspect of the project or participation therein, and can be reached at (914)493-6435. Members of the Lower Hudson Valley Perinatal Network will also be available to answer questions, and can be reached at (914)493-6435.</p><p>I, (name of youth participant) ______have read and received a copy of the Healthy From Birth For Life Consent Form. By signing this form, I agree to comply with the terms of the Consent Form as a program participant of Healthy From Birth For Life.</p><p>Signatures:</p><p>______Name of Participant (please print clearly) Date</p><p>______Signature of Participant Date</p><p>______Signature of Parent/Guardian Date</p><p>______Signature of Program Manager Date</p><p>______Signature of Investigator Date</p><p>95 Grasslands Road Valhalla, NY 10595 Phone: 914-493-6435 Website: www.LHVPN.net/HFBFL Fax: 914-493-1005</p><p>Lower Hudson Valley Perinatal Network organized in 2004 by the Maria Fareri Children’s Hospital Regional Perinatal Center with March of Dimes funding</p>