1. I hereby consent to allow my minor child/ward
to take part in the activities at the Youth Empowerment Zone. I understand that information about my child/ward and my family may be shared among Program staff and that the staff is required to keep such information confidential.
2. My child/ward’s part in this program:
a. He/she will answer a group of questions about him/herself in an effort to match him/her with a mentor, to evaluate the program, and most importantly to help staff learn how to best support him/her
b. He/she will spend approximately one hour a week with his/her mentor
c. He/she will fully participate in all or most sessions (at least 90%) of the Programs
3. How this program hope to help my child/ward:
a. Help him/her form a friendship with a volunteer mentor
b. Provide opportunity for him/her to learn new life and job skills
c. Provide opportunity to fully explore education and career options
4. I give Program staff my permission as the parent/guardian of this child to obtain attendance and academic (grade reports) records from my child/ward’s school in order to help Program better serve my child/ward whenever Program staff deems it necessary.
5. In addition:
a. I understand that his/her participation in this program is voluntary and that he/she can choose to leave at any time.
b. He/she has been told that if it is revealed that he/she has been abused that it will be reported to the proper authorities and that any information given while in this program may be subpoenaed and told in court.
c. I understand that the Program staff will keep any information (except for that in b. above) about me and my family confidential.
All my questions about the program have been answered. If I have any further questions about this program, I can contact Program Staff