Verbal Permission Form

Today's Date*

Teacher/Counselor/School staff making referral:*

First Last

Name of child being referred:*

First Last

School of child being referred:*

Grade of child being referred:*

Name of child's classroom teacher:*

Child's lunchtime (start and end time):*

Date of Birth of child being referred:*

Name of child's guardian:*

First Last

Relationship of guardian to child:

Suggested focus for mentor sessions:

I have relayed to the guardian the following:*

Guardian grants this child to meet with a mentor weekly at lunchtime. Guardian allow this mentor access to the child’s school and education related information that impacts supporting the child and grants permission for the child’s mentor to contact and communicate with guardian regarding Garrett Mentors activities and events and to possibly provide transportation to and from Garrett Mentors out of school activities if needed and planned out ahead of time. Guardian allow the child’s photo to be taken at school or program events for potential use in brochures, newspaper articles, website & on social media. Guardian will not hold Garrett Mentors Inc. or the mentor responsible for accident or injury going to, during an activity, or returning home.Guardian allows the child to be taken to Garrett Memorial Hospital in case of an emergency at a Garrett Mentors event if needed. Guardian will provide a phone number where they can be reached at all times.

I have:*

Received Verbal Permission from the chilld's guardian for child to join the Garrett Mentors program

Other: