LENA

Registration Below

Join today and receive a bag that includes books to help build your baby’s library, LENA shirt or vest for the baby, and a state-of-the-art baby pedometer. The pedometer is the tool we use to help calculate how many words you and your child are speaking.

Participating families earn the chance to win prizes, gift cards, and raffles! Families also get to learn about their baby’s language development and get tips and tricks to help your baby stay developmentally ahead.

Help us reach our goal of getting 1,000,000 conversational turns (baby words) in 2021!

LENA Start! Application & Informed Consent

By filling out and signing this form, you are applying to attend LENA Start parent sessions sponsored by For Oak Cliff. LENA Start is intended to help improve your child’s language development. If you are accepted and attend, you must agree to certain things that are outlined below. Please fill out this form carefully and read completely before you initial and sign on the other side.

NOTE: You must be the child’s parent or legal guardian to fill out this form and apply to the program. All information is required in order to apply and participate.

* Indicates required field

Child's Name *

First

Last

Child's Gender *

Male Female

Child's Clothing Size *

Child's Date of Birth *

Child's Age in Months *

Child's Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Caregiver *

First

Last

Relationship to Child *

Preferred Language *

Text Phone Number *

Receive program texts on this number *

Yes No

Email *

Secondary Caregiver *

First

Last

Relationship to Child *

Preferred Language *

Text Phone Number *

Receive program texts on this number *

Yes No

Email *

Childcare *

Childcare needed Childcare NOT needed

If previous answer if YES please provide the number of children *

Participant child's zip code *

Does the enrolled child have any brothers or sisters? *

Yes No

Note: Texts are a key part of this program and will be sent to those numbers with the ‘Receive program texts’ checkbox checked. You’ll receive about three texts (primarily reminders) per week from 855-960-0731, and data and message rates may apply. If you are not or are no longer able to receive texts, please speak with your coordinator immediately. You can cancel your receipt of these text messages at any time by texting STOP to 855-960-0731. For help with these texts or with LENA Start, see your coordinator, or text HELP to 855-960-0731.

Please initial each statement to show that you have read it, and that you understand and consent.

I am applying to attend LENA Start. I understand this includes using a small LENA recorder my child wears for a full day after each session, using special clothing. Recordings are done to generate information. They cannot and will not be listened to and will be deleted after they are processed. My child and people around my child will be recorded during recording days. I will do my best to avoid recording other adults without their knowledge and consent and to inform other adults that recording is going on and why.

Parent/Guardian Initial *

LENA Start is made up of 10 weekly sessions about 60-90 minutes long. In some cases, these sessions may be held remotely, requiring me to use my phone or personal computer to call in or connect via a tool identified by For Oak Cliff. If I am accepted and begin the program, I will attend sessions as scheduled, or arrange a makeup session if I have to miss a session. In order to graduate, I understand that I must:
1. Attend (or make up) all the first 4 sessions and at least 3 of the next 6 sessions
2. Turn in at least 6 LENA recordings

Parent/Guardian Initial *

Information that can be identified with me or my child will be kept confidential from anyone other than For Oak Cliff, LENA, and any affiliated professionals, all of whom will comply with all laws regarding confidentiality. I have read the note about texts on the previous page and agree that For Oak Cliff and LENA may use aggregated information for their own purposes in any way that does not reveal my or my child’s identity or violate any federal, state, or local laws or regulations, and in accordance with LENA’s privacy policy, available at lena.org/privacy-policy.

Parent/Guardian Initial *

The purpose of LENA Start is to improve child language development by teaching me practical techniques to increase personal interactions with my child. Specific improvements are not guaranteed. Instructors are not child development or healthcare professionals. If I have questions about my child’s health or development, I will consult a professional.

Parent/Guardian Initial *

If photos or videos taken during classes include me and/or members of my family, I give permission for use of these images by For Oak Cliff or LENA.

Parent/Guardian Initial *

LENA may provide the opportunity for me to complete ongoing language questionnaires until my child is 36 months of age. I agree to participate in this follow-up.

Parent/Guardian Initial *

AUTHORIZATION AND RELEASE

By signing below, I apply to attend LENA Start program sessions. I have read and understood this form, my questions about LENA Start have been answered to my satisfaction, and I agree on behalf of myself and my child to the conditions. I and my child do not give up any of our legal rights as participants in LENA Start.

Signature *

First

Last

Today's Date *

Submit

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LENA

Registration Below

LENA Start! Application & Informed Consent

Please initial each statement to show that you have read it, and that you understand and consent.

AUTHORIZATION AND RELEASE

Become a Member!

VOLUNTEER SIGN-UP!

DONATE TO OUR MISSION!

​LENA

​Registration Below

LENA Start! Application & Informed Consent

Please initial each statement to show that you have read it, and that you understand and consent.

AUTHORIZATION AND RELEASE

Become a Member!

VOLUNTEER SIGN-UP!

DONATE TO OUR MISSION!

LENA

Registration Below