MESA Utah Parent Permission & Student Information Form (SLC School District)
Parent Permission
Dear Parent or Guardian:

Your child has been invited to participate in the Mathematics, Engineering, Science Achievement (MESA Utah) program. MESA is an educational program designed to encourage and prepare students for college majors and careers in mathematics, engineering, science and related fields. MESA Utah assists these students by offering the following and more:

• Science, technology, engineering and mathematics (STEM) based project activities
• College and career guidance
• Field trips and academic competitions
• Scholarships & Outstanding Student Awards

Currently, more than 80 schools and 4,200 students throughout the state of Utah are involved with MESA. As a member of MESA, your child will be involved in fun, hands-on activities to teach him/her principles of math, engineering and science. He/she will participate in special field trips to universities and companies, competitions, and guest speakers that will expose them to exciting and financially rewarding career possibilities.

Permission Form:

I give permission for my child, (name listed below) to participate in the MESA Utah Program. I am in agreement with the goals of MESA. As a parent, I will encourage my child to strive to achieve these goals.

Additionally, I hereby grant the MESA/STEP Consortium of Utah and my school/district MESA program the right to obtain and/or use my child’s photograph, digitized image, video and/or voice recording for educational and informational purposes. I understand that such media and all subsequent uses of that media, including publications, presentations, web sites, videos and multimedia productions, become the property of the MESA/STEP Consortium of Utah and may be disseminated to the public via appropriate media channels.

I give permission for MESA/STEP Consortium of Utah to gather limited demographic and academic information about my child in the form below. This information will be used to create school MESA rosters. The information will also be used to track MESA participation throughout the state.

(Paper Version of Parent Permission Form: www.bit.ly/mesapermission)

I grant the permissions listed above.
Signature of Parent or Guardian: (By typing my name below, I am providing an electronic signature.)
Your answer
Student Information Form
Student First Name *
Your answer
Student Last Name *
Your answer
Student ID Number *
Your answer
District *
School *
Grade *
What school year did you first start participating in MESA? *
What year were you born? *
Gender *
Race or Ethnicity (Mark all that apply) *
Required
Career interests *
Required
This year I will be taking advanced classes in the following subjects (advanced classes include: Honors, GT, CE, AP, IB, etc.):
This year I may need tutoring in the following subjects: (Optional)
Do you have any special dietary requirements? (Optional)
Email Address (Optional)
Your answer
Cell Phone Number (Optional)
Your answer
Submit
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