MENTORSHIP PROGRAMME: 003

MENTORSHIP PROGRAMME PARENTAL CONSENT FORM

I, ____________________________/________________________/__________________________,

(Print parent's name)  First                                   Middle                                           Last

the parent or legal guardian of

_________________________________/_________________________/____________________
(Print child's name)   First                                             Middle                                      Last

Child’s Date of Birth

__________/_________________________/_________________ 

      (DD)                             (MM)                                 (YYYY)                                                       

Do hereby consent that my child / ward be granted permission to participate in the Christ is the Answer Family Church’s Mentorship Programme, unless and until I notify the church to withdraw this consent.

I have had the opportunity to review the Christ is the Answer Family Church’s Mentorship Programme. By executing the statement below, I authorize my child to fully participate in this programme.

I understand that participation in these activities may enable my child to disclose personal information (e.g., e-mail address) that will be accessible to others.

I also understand that my child’s information will be collected and processed as set forth in the Mentorship Programme’s privacy policy.  I understand that I may withdraw my permission granted herein, with written notice, at any time.

I also understand that it is important to provide accurate information in this consent form in case the Christ is the Answer Family Church or my child’s / ward’s Mentor or a representative of the Mentorship Programme need to contact me for any reason.

Signature of Parent / Legal Guardian

Dated this __________ day of _________________________________, 20__________.

___________________________________________________________________________________________________

PLEASE PRINT LEGIBLY

Parent's  / Guardian’s address:	_________________________________________________________
E-mail address:	_________________________________________________________
Child's e-mail address: (if applicable)	_________________________________________________________

Phone: Home    _____________________________

            Work     _____________________________

              Cell     _____________________________

List any medical or clinical condition which you think is important for the Mentor and or Programme Coordinators to know concerning your child / ward below (e.g., asthmatic, dyslexic, diabetic, etc.)

______________________________________________________________________________________________

NB: All information and discussions shared between parents / guardians and mentor and or programme representatives, including information shared between mentee and mentor will be held in strictest confidence.

OOW
2010