Cincinnati Youth Collaborative

Mentoring Parental Consent Form


I give permission for my child to participate in the Cincinnati Youth Collaborative mentoring program. I understand that all Mentors are volunteers, not school or CYC employees, and that mentoring activities with my child are intended to help him/her graduate from high school with the knowledge, skills, attitudes and behavior necessary to participate fully and responsibly in society.

I give permission for teachers and counselors in Cincinnati Public Schools and other CYC Partner schools to share information with the mentor(s), and CYC coordinator(s) about my child, including electronic (Power School) and physical scholastic/attendance records, as well as, any health or medical problems my child may have. I give CYC permission to share contact information with collaborative mentoring partners on behalf of my child.

I understand that mentoring may include activities that take place in and outside of the school, such as visits to the mentor(s) work site, home, and to cultural and recreational events. I consent to those. I also understand that special permission will be required each time my child participates in a mentoring activity outside the Greater Cincinnati Metropolitan Area, an overnight stay, or activities involving a degree of risk (canoeing, flying, etc.).

My child has my permission to go to mentoring activities in a private car driven by a mentor, in a bus, public transportation vehicle or in a vehicle driven by a school employee.

I grant permission for myself/my child to be photographed, recorded, or videotaped for CYC promotional and educational materials. I understand that this photograph, speech, or video may appear in various publications or marketing and media outlets for recruitment of volunteers. I also give permission for this material to appear on the CYC social media pages and website (www.cycyouth.org). I understand that this material may appear on television or other media for related promotional purposes, as well as in print or online for partner organizations. I give permission for my child to participate in program evaluation surveys and understand I may be required to complete occasional program evaluations.

I agree to indemnify and hold harmless the Cincinnati Youth Collaborative, its mentors, partner schools, Cincinnati Public Schools and their agents, employees and/or family members from any and all injury or damage arising from my child’s participation or non-participation in the mentoring program. I support the mentoring program, and will encourage my child’s participation. I understand that if my child does not adhere to the guidelines of the CYC Mentoring Program, he/she may be removed from the program.

Child’s Name: (PRINT)

Child’s Student ID:

Gender:

Address:

Race:  

US Citizen:

Parent/Guardian’s Phone: 

Leave this empty:

Cincinnati Youth Collaborative https://www.cycyouth.org
Signature Certificate
Document name: Mentoring Parental Consent Form
Unique Document ID: 7e83c86e5008731569a9bd2ac7ffeb10ec4c19a4
Timestamp Audit
April 11, 2019 2:47 pm EDTMentoring Parental Consent Form Uploaded by Chris Lipscombe - clipscom@cycyouth.org IP 192.168.1.189
April 11, 2019 3:11 pm EDTChris Lipscombe - clipscom@cycyouth.org added by Chris Lipscombe - clipscom@cycyouth.org as a CC'd Recipient Ip: 192.168.1.189
April 11, 2019 3:15 pm EDTChris Lipscombe - clipscom@cycyouth.org added by Chris Lipscombe - clipscom@cycyouth.org as a CC'd Recipient Ip: 192.168.1.189
April 11, 2019 3:17 pm EDTChris Lipscombe - clipscom@cycyouth.org added by Chris Lipscombe - clipscom@cycyouth.org as a CC'd Recipient Ip: 192.168.1.189
April 11, 2019 3:19 pm EDTChris Lipscombe - clipscom@cycyouth.org added by Chris Lipscombe - clipscom@cycyouth.org as a CC'd Recipient Ip: 192.168.1.189