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________________________________
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