Handout #7 - QIAMay4

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Sample contact and information release

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Handout #7 - QIAMay4

  1. 1. Sample Contact and Information Release(Note: Form to be completed by the parent/guardian or mentee if the mentee is under 18 years of age.This form may not be needed if permission to participate is requested on the general YouthBuildapplication.)[Program] Participant: __________________________________ Date: ________________School: _________________________________________________________I authorize _______________ to obtain any needed information regarding my son/daughter from his/herschool’s staff, including academic and behavioral records and conversations with teachers, counselors,and other administrative staff. I authorize the program to interview my son/daughter for the purposes ofmatching them with an appropriate mentor. I also authorize any additional information gathering and datacollection for the purposes of program evaluation and assessment, including the administration of surveysand participation in interviews and focus groups.Further, I understand that basic information about my child will be anonymously (without names) sharedwith a prospective mentor(s) to aid in determining a suitable match. Once a mentor/mentee match isdetermined, my child’s identity and other relevant information will be shared with the mentor to the extentit aids in facilitating a successful match.____________________________________________ _______________Parent/Guardian/Mentee Signature DateParent/Guardian/Mentee Name:____________________________________________________Address______________________________ City_____________ State____ Zip_____

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