LINC LITE Program Parental Consent Form
Dear Parent/Guardian; Your student has the opportunity to participate in the LINC/LITE Program, which builds essential life skills, strong identities, and pathways to success in middle and high school. These services include a self-affirming life-skills program that strengthens self-efficacy, communication, decision-making, financial awareness, goal setting, and healthy habits through mentoring, experiential activities, and community partnerships. We are requesting your permission for your child to participate. Please read & fill out the information below carefully before signing.
Student's Full Name
First Name
Last Name
Student's Date of Birth
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Month
-
Day
Year
Date
Consent & Permission
I, the undersigned parent/guardian, give permission for my child, named above, to participate in activities, programs, and services offered by the LINC/LITE Program.
I understand and agree that (please select all)
Participation is voluntary and can be discontinued at any time
LINC/LITE program staff may communicate and collaborate with teachers and school administrators to coordinate student excellence, report on progress, and provide support
Students information will be kept confidential, except as required by law or when necessary for their safety and well-being.
I release the LINC LITE program, its staff, volunteers, and partners from liability for any injury or harm that may occur during participation, except in cases of gross negligence or willful misconduct
Emergency Contact Information
Full Name
First Name
Last Name
Relationship to Student (i.e. parent, guardian, grandparent)
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Photo/Media Release
I also give permission for photographs, video recordings, or audio recordings of my child to be taken during participation in the LINC/LITE Program. I understand that these images and recordings may be used in program reports, training, promotional materials, social media, or other public communications related to the program.
Yes, I give permission for my child to be photographed/recorded for the purposes described above
No, I do not give permission for my child to be photographed/recorded
Authorization
By signing below, I confirm that I am the parent/legal guardian of the child listed above and that I grant permission for their participation in the LINC LITE Program.
Parent/Guardian Name (Print)
First Name
Last Name
Signature
Date
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Month
-
Day
Year
Date
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