Parent Authorization Form

NOTIFY IN CASE OF EMERGENCY
Name 		Relationship 	
Address 			
City _____________________________ State _____________ Zip Code 	
Home Phone ___________________________ Work Phone 	

PARENTAL CONSENT

I have read and understand the information given to my child about the Be a Mentor Program. I hereby give my permission for my child _______________________________, to participate in this program. I will assist my child in keeping all appointments with his/her mentor. I will attend all parent events and I agree to communicate with the Mentor Coordinator regarding any concerns I may have about my child’s participation in the Be a Mentor Program. I also understand that I will be given the opportunity to meet my child’s mentor. I also understand that my child will occasionally meet with his/her mentor at supervised scheduled events held at the school or other community center. Should an event be scheduled away from the school, I am responsible for my child’s transportation. 

All meetings between my child and his/her mentor held outside of the school setting, and not supervised by the Mentor Coordinator, shall be arranged by me, my child, and the mentor, and I take full responsibility for such meetings.
				
Date                                 	     Signature