Your permission is requested for your child, {studentName}, to participate in a youth internship program at Superhero Leadership Academy associated with your child’s school. Because the program may include confidential information (academic, data, evaluation, etc.) the supervisor of the program will keep information shared by the client confidential except in certain situations in which an ethical responsibility limits confidentiality.
You will be notified under the following circumstances:
1. The student reveals information about hurting himself/herself or another person.
2. The student or another person may be in physical danger.
By signing this form below, I give my informed consent for my child to participate in a youth internship program. I understand that anything that my child shares will be kept confidential except in the above-mentioned cases.
Parent/Guardian, {parentprimaryCaregiver}
**This consent will be on file throughout the time that your child continues in the program. You may
revoke this consent at any time. Please feel free to contact us if you have any questions.