MAC Permission Form

NOW ENROLLING FOR FALL 2024 - Our fall programming begins in September 2024.

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 family 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 Constance Hull at 804-643-2401 ext 121 or constance.hull@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

BoyGirlOther

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?

YesNo

Student Name*

First NameLast Name

Birth Date*

MonthDayYear

Grade*

K-5

Teacher *

Student's teacher

School*

Which school does your child attend?

Gender

BoyGirlOther

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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

YesNo

Student Name*

First NameLast Name

Birth Date*

MonthDayYear

Grade*

K-5

Teacher *

Student's teacher

School*

Which school does your child attend?

Gender

BoyGirlOther

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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

YesNo

Student Name*

First NameLast Name

Birth Date*

MonthDayYear

Grade*

K-5

Teacher*

Student's teacher

School*

Which school does your child attend?

Gender

BoyGirlOther

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Incarcerated Loved One Information

Name of incarcerated individual*

First NameLast Name

Relationship to student*

Name of facility where loved one is incarcerated *

Parent/Caregiver Information

Information of the person filling out this form.

Name*

First NameLast Name

Your relationship to the student*

Phone Number*

Alternative Phone Number

In case we cannot reach you.

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 participate in a brief phone intake 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.*

YesNo

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*

Date

Signature*

THANK YOU! We look forward to working with your child!

Permission Form

Student Information