MTA Leadership Program

MTA Leadership Program

Parent Consent Form MUST have a consent form signed by Parent & Student
Your child has been identified by their school administration as being able to benefit from a program called Mentoring Through Action(MTA), which is a leadership program designed by Mind Body and Soul Concepts, to encourage good choices, discipline, and leadership.MTA is designed to help your child succeed in school and prevent their involvement in negative behaviors. MTA will work to help your child discover and access resources to meet their individual needs and engage them in group and individual challenges to help them function optimally in the classroom. Through this program, your child may be involved in individual and group discussions, dialogue regarding issues they may be facing, reflection activities, guest speakers, mentoring, tutoring, and enrichment activities.

The program will require the review of school records. By allowing my child’s participation in this program, I hereby grant the right to the MTA Staff the ability to meet with my student in person, via Zoom, google meet or any similar platform and review my child’s school records (IEP’s, 504’s, etc.) for the purpose of monitoring my child’s progress. Parts of the program activities may be photographed and /or recorded. By allowing my child’s participation in this program, I hereby grant the right to the use of their name, likeness, performance and voice for the purpose of advertising or promoting the program. All photos and/or videos/DVDs are the exclusive property of SJUSD and Mind Body and Soul Concepts.

Note: Students and Parents MUST sign this document.

Date

DayMonthYear
Date
Student Name

First NameLast Name
Student Phone Number
Please enter a valid phone number.
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School
Parent/Guardian Name

First NameLast Name
Parent Email
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Relationship To Student
Alternate Parent/Guardian Parent/Guardian Name

First NameLast Name
Alternate Parent/Guardian Phone Number
Please enter a valid phone number.
Alternate Parent/Guardian Relationship To Student

Parent & Student Signatures

Parent and Student MUST sign this form.
I accept all the terms of this consent form and give my permission for my child to participate in the program, as specified above. I understand that there is no cost to me or my child.

My signature below indicates that I accept these conditions.
Parent Signature

Clear
Please use finger or mouse to sign
As a participant in the program mentioned above, I understand and agree to be responsible for my own actions and will conduct myself in an appropriate manner, at all times. I understand that violations of any of the rules will subject me to immediate removal from the program, and my parent (s) or guardian (s) will be notified.

My signature below indicates that I accept these conditions.
Student Signature

Clear
Should be Empty:

Parent & Student Signatures