Community Connections
Berlin Calais East Montpelier , Middlesex, Montpelier Worcester
Bringing School and Community
Together
Girls/Boyz First!
Mentoring
Student Release
of Information Form
As parent or legal guardian of __________________________________________,
Student’s name
►I give permission to
____
____
to release
academic and/or behavioral information to:
____ Girls/Boyz First! Mentoring Program’s
Coordinator ____ my child’s mentor
The information
may include (check what you will
allow to be shared):
____grades
____special
education records ____social/behavioral
information ____health information ____homework information ____other______________________
specify
►I give permission for my child’s teacher, _____________________, to speak to my child’s mentor in regard to my child. ___yes ___no
►I give
permission for my child’s ___guidance counselor ___nurse
___principal
____other______________________ to speak to my child’s mentor in regard
to my child.
specify
►I give permission to Girls/Boyz First Mentoring
program to release records and/or information to: ____
____
►I give
permission for my child’s mentor to speak to my child’s ___teacher ___principal ___guidance counselor ___nurse
___other___________________ in regard to my child.
Print
name
________________________________________________________________________________________________
Signature of parent/legal guardian Date
Girl’s/BoyzFirst!! Program Coordinator’s Name:_________________________________
Any information shared will remain
confidential and will not be shared with others.
►Parents:
what else would you like to tell us to help Girls First/Boyz First work
together with the schools to help your child?