Story Telling - PARENT/GUARDIAN CONSENT FORM

Parent/Caregiver Name: *

First Name Last Name

Phone Number: *

Please enter a valid phone number.

Email *

example@example.com

How did you hear about the program? *

What Region do you reside (eg. Vaughan, Markham etc) *

Student Name: *

First Name Last Name

Student Date of birth *

Date

Gender (if you don't want to answer just say N/A) *

Nationality *

How do you identify your child (eg. African Canadian, African, Black, Caribbean, Mixed Or Other. * *

Student Phone Number (If they don't have one just say N/A) *

Student Email (If they don't have one just say N/A) *

example@example.com

School *

Grade *

Does your child have any special needs. *

Yes No

Do you need tutoring? *

Yes No

If yes, which courses do you need tutoring for?

Which Grade?

I, the parent or legal guardians for child/student named above hereby allow my child’s permission to participate in the Sankofa Storytelling Program.

I fully understand that the program involves mentors, who shall be selected from the community and will be screened (including a criminal background check) and trained before beginning in the program. I understand that Mentor(s) will be expected to spend a minimum of two hours per week with my child Online at the Sankofa Program.

PHYSICAL / IN PERSON
York Region Alliance of African Canadian Communities will not be responsible for any loss or damage belonging to your child
• Your child will follow all rules and reasonable instruction while participating in the program.
• York Region AACC board, staff and volunteers shall not be responsible for any loss , damage or injury by anyone in the course of their voluntary attendance and / participation in the Program

I consent to my child's participation in the Sankofa Story Telling & Mentoring program and give him/her my permission to participate. I understand that my child will be participating in various activities with a volunteer mentor, and that he/she will be under that programs supervision during those activities. *

Yes No

I understand that my child's participation in Sankofa Story Telling & Mentoring Program and sponsored activities and specific activities is voluntary. *

Yes No

I understand that I will be expected to attend ONLINE /IN PERSON orientations, meetings and celebrations associated with the program, and will encourage / motivate my child to participate and discuss topics with me. *

Yes No

I give my permission to the Sankofa Story Telling and Mentoring Staff and/or Mentor(s) to pick up, or transport my child for activities and events that are planned and organized by the program in person as per the government mandated protocols. *

Yes No

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. *

Yes No

I give my permission for my child's name, likeness and speech in any audiotape, videotape, film or photograph, artwork, stories, or quotes made at any Sankofa Story Telling & Mentoring Program activities for public relations or outreach purposes. I waive all rights to compensation. *

Yes No

I have been informed as to the purpose and duration of the program. I have also been informed as to the programs expectations concerning the involvement of the mentor(s), my child, and parents. *

Yes No

Story Telling Registration Form

Emergency Contact (For Face to Face Interactions)

Parent Consent