Girls Leading Our World

Girls Leading Our World
2024-2025 Academic Year

Parent/Guardian Consent Form

We are excited that your daughter is interested in joining the Girls Lead Our World (GLOW) Program! Your permission is needed for your child's general participation in the GLOW Mentoring Program and the release of information for your child's grades, attendance, and behavior. Please complete and submit this form for your child's participation in the program.

CONSENT TO PARTICIPATE: I consent for my daughter, to participate in the GLOW mentoring program sponsored by Durhams Hope For Kids. GLOW meets in person weekly or bi-weekly for 60-90 minutes. I am aware that Durhams Hope For Kids is a local 501(c)(3) nonprofit organization that offers mentoring programs for girls and participation involves meetings, group outings and community service. I agree to hold harmless Durhams Hope For Kids against any liability, loss or expense incurred or suffered in consequence of any action or actions, suit or suits, in law or equity, which may be brought by any person or persons in connection with, or with reference to, the administration, planning, preparation, development, conduct and execution of the GLOW mentoring program. I understand that my child may engage in discussions pertaining to drugs, alcohol, sexual behavior, dating, violence and other sensitive topics. I understand that my daughter will participate in the program from Fall 2024 to Spring 2025.

Name of daughter/mentee*

First NameLast Name

VIRTUAL MENTORING: On occasion, we will host virtual experiences. Please provide permission for your daughter to participate in virtual group mentoring with the Girls Leading Our World Program. I understand that the organization has taken measures to ensure a safe interaction(s) with her mentors such as interviewing, training, and comprehensive background checks.

Parent initial below.*

RELEASE OF SCHOOL RECORDS/INFORMATION: I, the undersigned, consent to Durhams Hope For Kids and their GLOW program and evaluation staff to have access to my daughter’s school records. I agree to allow my daughter’s school to release their school records including grades, attendance and discipline records for the purpose of research and presenting impact data. I understand that my daughter will complete a confidential survey about her attitudes and opinions about the program as part of an evaluation. I understand that the information provided by the school and my daughter will be statistically analyzed and that my daughter’s name will be withheld for confidentiality purposes. I understand that this information, in addition to the survey, will be a component of the larger evaluation process and only the program and evaluation staff will have access to the confidential information.

TRANSPORTATION: When possible and if necessary, I, the undersigned, hereby grant permission for the GLOW program staff/volunteers to transport my daughter to and from various activities and hold harmless Durhams Hope For Kids against any liability, loss or expense incurred or suffered in consequence of any action or actions, suit or suits, in law or equity, which may be brought by any person or persons in connection with, or with reference to, the administration, planning, preparation, development, conduct and execution of the GLOW mentoring program. Parents will be notified in advance if transportation will not be provided to an outing or event. Parents will then be responsible to secure transportation for their daughter to participate in an event or outing.

PHOTO RELEASE: I, the undersigned, hereby grant permission to Durhams Hope For Kids to take and reproduce photographs for publication, including publication by news sources and other sources for all educational, trade, advertising and other purposes as determined by the GLOW Program. These images may be used for GLOW displays, brochures, newsletters, archives, news releases, publicity, social media and Websites.

Mentee must agree to participate in the Girls Leading Our World (GLOW) Mentoring Program and agree to: Meet with my mentor every week or every two weeks during the scheduled time. Notify my mentor if I cannot meet with her for any reason. Attend all required program activities outside of meetings at school. Participate in outings, field trips, community service projects and GLOW Events. Communicate with my mentor and/or Program Facilitator if I feel uncomfortable or experience problems during the program. Abide by the rules and regulations of the school and the Girls Leading Our World Mentoring Program.

Section l: Parent/Guardian Information

Name of Parent/Guardian*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Part II: Emergency Contact Information

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone*

Please enter a valid phone number.

Part III: Daughter/Mentee Information

Daugher/Mentee Name*

First NameLast Name

Date of Birth*

Date

Daughter/Mentee Phone Number (Please provide mobile number)*

Please enter a valid phone number.

Daughter/Mentee Email*

example@example.com

Daughter/Mentee School Name*

Grade*

Daughter/Mentee Lives With*

Does your Daughter/Mentee receive one of the following?*

Daughter/Mentee T-shirt size*

Part IV: Parent/Guardian Additional Information & Signature

What is your relation to the Mentee?*

What three words would you use to best describe your daughter?*

What type of changes would you like to see in your daughter after participation in GLOW?*

Are you willing to volunteer and/or support the organization? If yes, in what capacity?*

Is there any additional information you would like us to know about your daughter that will be helpful in mentoring her?*

By signing/printing your name below, you have read and completed the above consent form and are providing consent for your daughter to participate in the GLOW Program.

Signature of Parent/Guardian*