2021-2022 School Year Parent Permission/Consent and Student Enrollment Form
Please fill out one form per child/student (3rd-12 grade).
Sign in to Google to save your progress. Learn more
MEGA will not share the data collected on this form. It will only be used for the purposes of this program.
Virtual Mentoring
In an effort to continuously serve the MEGA Mentors Mentees, during this time of COVID-19 when schools are closed and/or have modified in-person gatherings, MEGA Mentors is going to provide virtual mentoring and reading programs, which may include video and web-based programs.

This consent form covers all forms of virtual mentoring programs.  I understand that I am registering my child for a virtual course and that my child’s image may be transmitted during video portions of the virtual mentoring and reading programs.

Additionally, I understand that the information provided may include but not limited to:  student’s age, address, telephone number, age, school name, student grade in school, student’s email address, student progress and course grades.  In order for your child to participate in the virtual mentoring or reading program, you agree to provide the following:  a computer, phone, or tablet and internet access that will be used to access the virtual mentoring or reading programs.

MEGA Mentors will use software, tools and applications provided by third parties that members, parents/guardians and/or CCPS staff will access via the internet and use for purposes of communication and programming.  These platforms include Google Meets and Zoom.

MEGA Mentors is committed to providing a safe and secure environment for our Mentees and that commitment is extended to our virtual mentoring and reading programs.  Therefore, MEGA Mentors will make every effort to protect Mentee information, by monitoring and maintaining control of, and access to the data collected; prohibiting re-disclosure of Mentee information; limiting the purposes for which the online platforms may use Mentee information; ensuring there is no advertisement and that no Mentee’s information is collected for commercial purposes. Furthermore, all virtual mentoring activities (e.g., Google Meets and ZOOM sessions [including breakout rooms]) will be conducted by a minimum of two adult Mentors.

Further, MEGA Mentors virtual mentoring and reading programs will comply with CCPS policies and procedures.  If there are any issues, challenges or concerns that arise during the virtual mentoring or reading programs, please contact the MEGA Mentor Liaison for prompt resolution.

In Person Mentoring
Only applies if CCPS allows in-person gatherings with appropriate social distancing guidelines.  The MEGA Mentors Mentorship Program is designed to support, reinforce, and reflect the academic and social values of Chesterfield County Public Schools with the goal of ensuring the student’s academic and social success. Participants will meet as a group, during the School’s enrichment period or class time, approximately two times a month, which may result in your student missing some instructional time; or four times a month for the elementary school reading program.

I understand that there may be video or photographs taken of my child during the mentoring sessions, field trips, forums and outside events to document the activities, and I further understand that in signing the Permission Form, I am allowing MEGA Mentors to use the videos or photographs of my son/daughter for MEGA Mentors related promotional materials.

Additionally, I, give my son/daughter permission to attend and participate in MEGA Mentors sponsored field trips, forums and events outside of his/her school during the 2020-2021 academic school year and to have the video or photographs of my child used for MEGA Mentors related promotional materials.    
Please initial: *
Enter your two or three letter initials to consent to the above paragraph.
Additionally, I understand that in order for MEGA Mentors to effectively assist my son/daughter in his/her academic pursuits and to effectively mentor the student, I grant permission to the School to release the student’s grades, progress reports and other academic and discipline related information to MEGA Mentors.  Such waiver however will not extend to MEGA Mentors sharing the student’s grades, progress reports and other academic and discipline related information with a third party.
Please initial: *
Enter your two or three letter initials to consent to the above paragraph.
MEGA Mentors has taken steps to be in compliance with federal legislation for child protection, including The Family Educational Rights and Privacy Act FERPA -http://www.ed.gov/offices/OM/ferpa.html); and the Children’s Online Privacy Protection Act (COPPA http://www.ftc.gov/os/1999/9910/64fr59888.htm).
Child/student's last name: *
Child/student's first name: *
Child/student's gender: *
In which grade is your child/student? *
Which school does your child/student attend? *
Would you prefer your child attend a 30 minute virtual mentoring session at school, an after school virtual session from 5:30-6:30 pm or both? *
Note: both at-school and virtual sessions will be conducted twice a month. The at-school mentoring days/time are TBD; the mentors will conduct the session virtually. The virtual session days are TBD.
Parent/Guardian's first and last name: *
Parent/Guardian's home address: *
Parent/Guardian email: *
Parent/Guardian's cell phone: *
Enter N/A if not applicable.
Parent/Guardian's home phone: *
Enter N/A if not applicable.
Parent/Guardian's work phone: *
Enter N/A if not applicable.
Checking the box below indicates I have read this agreement and accept the rules of the MEGA Mentors mentoring and reading program.
I understand the terms of this permission form and give my consent. *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy