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Date: _______________
Student’s Name: __________________________________ Age: _______
Parent/ Guardian’s Name: ______________________________________
Address: _____________________________________________________ ____________________________________________________________
Home Phone: _______________________ Work Phone: __________________
Parent E-mail:__________________________ Student E-mail: __________________
Is there any information you would like us to know about your child? Likes/ Dislikes?
__________________________________________________________________________________________________________________________________________ _____________________________________________________________________
Mentors Matter’s The Bridge Agreement/ Permission Form
I give my child, _________________________________, permission to participate fully in Mentors Matter/The Bridge mentoring program. 1. I will help to have my child keep his/her scheduled times with their mentor. 2. I will be informed by the mentor as to when my child will meet with his/her mentor and what they plan to do. 3. I give permission for my child to travel with their mentor and the Mentors Matter Director in their vehicle. 4. I understand that my child will also be required to participate in monthly Community Outreach outings to The Parkesburg Point, FLCC & the Harrison House in Christiana, PA to spend time with the elderly and/or other opportunities and hereby give my permission for him/her to do so. 5. I understand that there will be planned family events for family, child and mentor to meet and interact and I agree to be in attendance, to the best of my ability.
Parent or Guardian Signature____________________________________ |
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Mentors Matter’s The Bridge |