Parent/Guardian Consent Form

Terms and Conditions

Please complete all blanks and parent/applicant sign in wherever necessary.

Section I: Permission to Participate

I have read the Terms & Conditions concerning the internship program and give my son/daughter, ______________________________________________________, permission to participate in the program. I realize that each student must provide his/her own transportation to and from the internship workplace site. I realize that SPARK SIP cannot directly supervise him/her and understand that it will not be liable for any injuries that he/she may sustain as a result of this experience. I also understand that my son/ daughter must meet the application requirements to be accepted into the program.

___________________________________________________________________________________

Signature of Parent/Guardian Date

Section II: Emergency Authorization

In the event that I cannot be reached in an emergency, I give permission to the internship workplace supervisor to secure proper treatment for my son/daughter.

Daytime telephone: _________________

In case of emergency, contact________________________________

Telephone: ____________________________________________

Proof of Health Insurance:

Physician Name: _____________________________________

Phone #: ___________________________________________

Physician’s Address: _________________________________________________________________

Insurance Company: ______________________________________________________________

Policy Holder’s Name: ________________________

Insurance Policy Number: _______________________

__________________________________ ______________________

Signature of Parent Date

Section III – Applicant

I,_______________________________________________ hereby grant permission for my name to be placed in candidacy for selection in the SPARK SIP. I request that all school data in support of my nomination be at the disposal of the SPARK SIP. In addition, I waive my right to view recommendations sent by teachers, coach, or supervisors.

_____________________________________________________________________________________

Applicant's Signature Date