Youth Empowering Services Guardian Permission Form

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Email *

Guardian Name *

Guardian Contact Number *

Relation to the Student *

Student's Name *

Student's Grade *

Student's Teacher *

Which school does your student attend? *

Webster Elementary

Lemmer Elementary

Escanaba Upper Elementary

Escanaba Junior High School

Escanaba Senior High School

Cameron Elementary

Jones Elementary

Gladstone Middle School

Escanaba Student Success Center

Bark River Harris

Carney Nadeau Public Schools

Other:

What do they like and dislike, their hobbies, personality, etc. *

Does your child have any aversions or food allergies that we should know about? *

I hereby grant permission for my daughter/son to participate in the Y.E.S In School Mentor Program. I understand and acknowledge that this program is voluntary, and there is no requirement that my daughter/son participates in this program. Further, I understand that the individuals who serve as mentors in this program are volunteers and are not employed by the Escanaba School District. As a general rule, all meetings between the student and the mentor will occur at the school during regular hours. I understand that I may withdraw my permission at any time by written notification to the principal, and that my daughter/son will thereafter be withdrawn from the mentor program.
*

I Agree

I give permission to Y.E.S to use pictures of my student taken during programming to be used to promote the program on their facebook page.
*

I give permission

I do not give permission

I give permission for my student to receive resources from the Y.E.S. program *

I give permission

I do not give permission

I'd like more information

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