Girls Taking Action Parent Consent & Permission Form 2020-2021
Complete this form in its entirety.
Name of Student(s) Participating in the Girls Taking Action Program *
Permission and consent for your daughter/dependent to participate in the Girls Taking Action Program. (State your name) *
Parent(s) Name: *
Address: *
Home Phone: *
Cell Phone: *
Email: *
Are you on Facebook? If so, what is your Facebook name? *
Would you consider volunteering as a mentor in the Girls Taking Action Program? *
Permission for Trips: My daughter/dependent has permission to travel to, attend and participate in any and all Girls Taking Action sponsored activities that are less than four hours' drive from meeting location, two nights or less, and not considered high-risk activities as outlined by Girls Taking Action. I understand lead mentors will follow Girls Taking Action Program standards and Activity Safety Checkpoint ... *
Required
Permission for Use of Photos: I hereby consent that the videotapes, photographs, motion pictures, electronic images and/or audio recordings of my daughter/dependent may be used by Girls Taking Action for public relations and publicity purposes to include but not limited to newspapers, printed materials, website and social media. I understand that her last name and residence will not be used for publicity purposes by Girls Taking Action without prior parent consent. *
Authorize Release of Information: I, undersigned, authorize the release of school data (academic and behavioral) to the Girls Taking Action TM Program for my NAMED BELOW STUDENT(S). The data will be used to mentor students to improve their grades, improve academic engagement, improve behavior, improved graduation rates and prepare for college entrance. *
Required
Permission for Emergency Medical Treatment: In the event of an emergency, every effort will be made to contact a parent/guardian or emergency contact. If no contact can be made, I hereby give authorization to Girls Taking Action to seek treatment for my child and/or dependent minor by a licensed physician pursuant to Minnesota law. I know of no reason(s) why my daughter/dependent may not participate in prescribed activities except as noted on the Health History Form. If permission for emergency medical treatment is not given, please prepare a signed statement providing the reason, a release of liability, and alternate instructions, and email to giavolunteers@jcama.com. *
Emergency Contact #1 (Name, Phone Number, Relation to Child): *
Emergency Contact #2 (Name, Phone Number, Relation to Child): *
Parent Agreement: I have read and understand this annual permission and consent form. I may change or revoke any aspect of this agreement at any time by submitting my request, in writing, to the Girls Taking Action main office staff. 600 18th Ave N. Minneapolis, MN 55411 E-Signature(s) & Date: *
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