Parental Permission Form printable pdf download

NISD Mentor Program

Parental Permission Form

________________________________ School

I hereby grant permission for my daughter/son to participate in the School Mentor Program. I understand and

acknowledge that this program is voluntary, and there is no requirement that my daughter/son participates in this program.

Further, I understand that the individuals who serve mentors in this program are volunteers and are not employed by

Northside Independent School District. As a general rule, all meetings between the student and the mentor will occur at

the school during regular hours. If any other contacts are planned, the school/mentor will obtain advance, written parental

permission. Finally, I understand that I may withdraw my permission at any time by written notification to the principal,

and that my daughter/son will thereafter be withdrawn from the mentor program.

If you would like your child to participate in the mentoring program, please check YES. If you do not want your child to

participate in the mentoring program, please check NO.

YES ____

NO ____

If you check YES, please complete the form below and return it to your child’s teacher by the end of this week.

If you checked NO, please return the form to your child’s teacher.

Sincerely,

Mentor Coordinator/Principal

SCHOOL _______________________________________________

MENTORING PROGRAM

Student’s Name ____________________________________ Age _____________________________

Student’s Adress ___________________________________ Grade ____________________________

City, State, Zip _____________________________________ Teacher __________________________

Student’s Home Phone _______________________________ Work Phone ______________________

Parent’s Name(s) _____________________________________________________________________

I, the undersigned parent or legal guardian of the above student, do hereby consent and agree that the above-named may

participate in the ______________________________________________ mentoring program during the school year of

20 ___ to 20 ___. I understand that information regarding the student’s progress in reading, math, and language arts may

be shared with a mentor/tutor.

Parent/Guardian Signature___________________________________ Date ___________________

Parental Permission Form