I,   First Name   Last Name   (Parent/Legal Guardian Name), am the parent/legal guardian of the above-named participant. I hereby authorize the Berkeley Community Violence Intervention Program (BCVI) to share and receive information related to the participant's involvement with schools and probation. This includes, but is not limited to, attendance records, academic progress, disciplinary actions, probation status, and compliance with probation terms.

I understand that this information will be used by BCVI to provide appropriate support and services to the participant. I also understand that this information will be kept confidential and will only be shared with authorized personnel within BCVI, schools, and probation departments as necessary for the participant's well-being and program participation.

I understand that I have the right to revoke this consent at any time by providing written notification to BCVI.

I understand that BCVI staff are compelled by law to inform appropriate persons and/or agencies if they believe the participant is in danger of hurting themselves or someone else, or if there is reasonable suspicion that a child, dependent adult, and/or elder adult has been abused.