MAC Permission Form

NOW ENROLLING FOR FALL 2026, with programming starting in SEPTEMBER 2026.

The Milk and Cookies (MAC) Children’s Program is a unique, school-based program just for students with an incarcerated (or recently released) parent, caregiver, or significant household member.

MAC groups meet weekly, by grade level, during your child’s ENCORE period, so it does not interfere with academic time. We follow a 20-week curriculum exploring topics of self-esteem, grief and loss, anger management, and more. We use group discussions, books, games, and fun activities to help us talk about what it’s like to have an incarcerated parent or family member.

After completing this permission form, you will be called to complete a brief intake about your student and family.

Please contact us at 804-643-2401 or email sam.lichtenstein@afoi.org if you have questions.

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Student Name:

First Name Last Name

Birth Date

MonthDayYear

Grade

K-5

Teacher

Student's teacher

School

Which school does your child attend?

Gender

Other

Address

Street Address

Street Address Line 2

City (ciudad)State (estado)

Zip Code (código postal)

Do you have additional children in your household you wish to enroll?

Student Name

First NameLast Name

Birth Date

MonthDayYear

Grade

K-5

Teacher

Student's teacher

School

Which school does your child attend?

Gender

Other

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have additional children in your household you wish to enroll?

Student Name

First NameLast Name

Birth Date

MonthDayYear

Grade

K-5

Teacher

Student's teacher

School

Which school does your child attend?

Gender

Other

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have additional children in your household you wish to enroll?

Student Name

First NameLast Name

Birth Date

MonthDayYear

Grade

K-5

Teacher

Student's teacher

School

Which school does your child attend?

Gender

Other

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Incarcerated Loved One Information

MAC works with students who have an incarecerated parent, caregiver, or significant household member. We also serve students up to one year after the release of their loved one.

Name of incarcerated individual

First NameLast Name

Relationship to student

Did the child(ren) live with this person prior to their incarceration?

Name of facility where loved one is incarcerated (or release date if recently released)

Parent/Caregiver Information

Information of the person filling out this form.

Name

First NameLast Name

Your relationship to the student

Phone Number

Format: (000) 000-0000.

Alternative Phone Number

In case we cannot reach you.Format: (000) 000-0000.

E-mail

example@example.com

Informed Consent and Acknowledgement

By signing I state that I am the parent, legal custodian or caregiver of the above child and I thereby give the above-named child permission to participate in the Milk and Cookies Children’s Program. I agree to complete an intake and waiver with an AFOI Program Facilitator before my child begins participating in the program and failure to do so may result in my child being ineligible for services. I understand that my child will be taught by professional staff, Masters level facilitators, and may be assisted by trained volunteers. Researchers from The College of William & Mary will be evaluating the program and will be talking with your child to help with the evaluation. As part of this evaluation, attendance information and grades will be collected. Please contact AFOI (804-643-2401) if you would like to opt out of an evaluation component.

The MAC Program has my permission to use this child(ren)’s image(s) in printed and audio-visual materials.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Date

Signature

Permission Form

Student Information