Parent consent form
Student full name
*
First Name
Last Name
School and grade
*
Parent or guardian full name
*
First Name
Last Name
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred contact method
*
Yes
No
Alternate contact person and phone
Section 2: Consent to Participate
I give permission for my student to participate in the South Rome Free Tutoring Program including on site and virtual sessions. I understand this program is free and operated by volunteers.
I consent for my student to participate
*
Section 3: Media and Sharing Consent
I consent or do not consent to the program photographing or recording my student and to the use of first name, reviews, artwork, or school related work for positive program updates, reports, and outreach. No addresses or private data will be shared.
Media consent
*
Yes
No
If Yes, allow use in
Section 4: School Communication Consent
I consent or do not consent to program staff communicating with my student’s school counselor, teacher, or other school personnel to coordinate support for academics and well being.
Consent to speak with school staff
*
Yes
No
If Yes, list staff names and school emails
Section 5: Advocacy Consent
I consent or do not consent for the program director or an approved representative to advocate for my student or family in areas related to academics, attendance, behavior, or school meetings. Any advocacy requests will be submitted through the Support Request Form.
Advocacy consent
*
Yes
No
If Yes, primary concerns
Submit a Support Request Form (URL)
Section 6: Schedule and Availability Acknowledgment
This volunteer nonprofit schedules sessions based on tutor and mentor availability. College and adult schedules can change. Service may be paused during school breaks or when tutors are unavailable. Submission of this form does not create an automatic weekly schedule. We match each student with a tutor or mentor based on need and coursework. If no match is available your student may be placed on a waiting list. Some support is offered while you wait.
I understand the scheduling policy
*
Section 7: Attendance Policy
Three missed sessions without advance notice will pause participation until the situation is reviewed and the student is approved to restart.
I understand the attendance policy
*
Section 8: Conduct and Respect Policy
All families agree to a safe and respectful program environment. No profanity, threats, or screaming. Respect the rules, the director, volunteers, and staff.
I agree to the conduct policy
*
Section 9: Communication
Send email or call and leave a message as the preferred methods of contact. The director is not required to respond immediately. Updates may come from the assigned tutor or mentor.
Best times to contact you
I understand the communication policy
*
Section 10: Collaboration with School Resources
Program staff may share general resources and suggest materials, websites, or tools that work in partnership with school personnel.
I acknowledge collaboration with school resources
*
Section 11: Disclosures and Agreement
I acknowledge receipt of this agreement. I have read, discussed, and understand the policies and process. I agree to ethically join the program and partner with staff to best assist my student.
Initial here to confirm you read and discussed this
*
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: