2024-2025 School Year Parent Permission/Consent and Student Enrollment Form
Please fill out one form per child/student (3rd-12 grade).

If you have any questions, please contact the program director at programs@megamentors.org.
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Email *
MEGA will not share the data collected on this form. It will only be used for the purposes of this program.
In-Person Mentoring
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.

Current in-person mentor programing is available at the 12 following CCPS locations: Curtis Elementary, Ecoff Elementary, Ettrick Elementary, Hening Elementary, Falling Creek Middle, Manchester Middle, Providence Middle, Salem Church Middle, Meadowbrook High, LC Bird High, Manchester High, and Carver College and Career Academy.

I understand that there may be video or photographs taken of my child/student 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 child/student for MEGA Mentors related promotional materials.

Additionally, I, give my child/student permission to attend and participate in MEGA Mentors sponsored field trips, forums and events outside of his/her school during the 2024-2025 academic school year and to have the video or photographs of my child/student used for MEGA Mentors related promotional materials.    
Virtual Mentoring
In an effort to continuously serve all CCPS students, regardless of whether MEGA Mentors has an in-person program at a specific CCPS location, MEGA Mentors provides 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 is 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/student 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/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 Meet 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.

Please initial: *
Enter your initials to consent to the "In-Person Mentoring" and "Virtual Mentoring" statements above.
Student Academic Release
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.

MEGA Mentors has taken steps to be in compliance with federal legislation for child protection, including the Family Educational Rights and Privacy Act FERPA and the Children's Online Privacy Protection Rule ("COPPA")
Please initial: *
Enter your initials to consent to the "Student Academic Release" statement above.
Child/student's last name: *
Child/student's first name: *
Child/student's gender: *
Is your child Hispanic or Latino/a?
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What is your child's race?
Select all that apply.
In which grade is your child/student? *
Which school does your child/student attend? *
Required
Would you prefer your child attend a 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. 
Required
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. *
Required
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