CHC Mentoring Parent/Guardian Permission

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The Center for Humanistic Change is a non-profit agency in Allentown that gives people, especially youth, the knowledge and tools they need to make better-informed and more positive life choices. The CHC offers student mentoring in your child's school during the school day. Mentors meet with students in small groups, or individually, and provide support with communication; appropriate expression of emotions; problem-solving; and/or resolving conflict effectively.

School Name *

Student Full Name *

Student Grade *

Today's Date *

YYYY

I, hereby, give permission for my student to meet with a mentor at school if referred by school staff. (Please Print Parent/Guardian Name) *

Parent/Guardian Contact Number *

I hereby authorize the Center for Humanistic Change, Inc. to use my child’s photo for publicity purposes in newsletters, brochures, website, etc.
*

Yes

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