Please complete the Parent Permission Form below and submit.   You may print and fill out the PDF form on the right, if you prefer. You can then either email or mail the form back to us at info@1on1mentoringtucson.org or  P.O. Box 89729  Tucson, Arizona 85752.

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PARENT/GUARDIAN PERMISSION FORM
I,your full name
as Parent/ Guardian(s) ofchilds name
, understand the nature of the One On One Mentoring program as described in the One On One Mentoring Brochure and Fact Sheet and willingly request a mentor for my child. I understand that One On One Mentoring will not deny my child's participation in the program solely based on any one of the following statements.
PLEASE INITIAL:
1. I consent to my child's participation in the One On One Mentoring program and give him/her my permission to participate;
2. I will do everything I can to help him/her meet the program requirements;
3. I will fully support my child's relationship with the One On One Mentor. Should I need to discipline my child, I agree that discipline would not automatically include denial of contact with the Mentor;
4. I hereby give consent for the One On One Mentoring Mentor Coordinator, Mentor or staff to obtain appropriate emergency medical or dental attention for my child, if such attention is required while I am unavailable or unable to be contacted;
5. I give my permission for One On One Mentoring Mentor Coordinator or staff to share and access information with other agencies and professional persons working with my child, including but not limited to, psychological, medical, and school/educational information, including grades, test results and attendance;
6. I agree to provide the One On One Mentoring Mentor Coordinator or staff with copies of my child's school report cards upon request;
7. I give my consent for the One On One Mentoring Mentor or the Mentor Coordinator to share information regarding my child's progress and the status of the match with referral or other agencies, as appropriate;
8. I give my permission for my child's name, likeness and speech in any audiotape, videotape, film or photograph made at any One On One Mentoring activities for public relations or fundraising purposes of One On One Mentoring. I also give consent for any printed materials, artwork, stories, or quotes from my child to be used for public relations or fundraising purposes;
9. I give my permission to the One One One Mentoring mentor and/or Mentor Coordinator or staff to visit, pick up, or transport my child for activities and events;
10. I give my permission to the One On One Mentoring Mentor and/or Mentor Coordinator or staff to visit, pick up and be an advocate for my child at his or her school;
I understand that my child will be participating in various one-to-one activities with a volunteer mentor, and that he/she will be under that volunteer's supervision during those activities. I release One On One Mentoring, its officers, agents, employees and volunteers from any and all liability, claims, demands or causes of action whatsoever that I may have as Parent/Guardian of this youth, for damage, loss or injury to him/her which may occur while participating in any of the activities contemplated by this Agreement, whether caused by the negligence of One On One Mentoring, its officers, agents, servants, or employees, or by the negligence of the One One One Mentoring volunteer, or otherwise. I understand that my child's participation in One On One Mentoring sponsored activities and specific activities with his/her mentor is voluntary. By my signature below, I hereby acknowledge that I have read and understand this document and the items contained therein, and that I have received a copy of this document for my records.
Signature of Parent/Guardian
Printed Name Parent/Guardian
Date
Signature of One On One Staff Member
Printed Name of One On One Staff Member
Date
Emergency Medical Consent
I give consent for the Mentor or One On One Mentoring representative to obtain appropriate emergency medical or dental attention for;
Menteechilds name
should such attention be required while I am unavailable for contact.
Name of Primary Care Physician
Physicians Phone
I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN ONE-ON-ONE MENTORING AND/OR ITS AFFILIATED ORGANIZATIONS AND MYSELF AND HAVE SIGNED IT OF MY OWN FREE WILL. THIS CONTRACT IS IN EFFECT UNTIL CANCELLED IN WRITING.
Signature of Parent/Guardian
Witness signature
Date
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