CONSENT

This form primarily gives the description of events provided by V-ELMS and asks parents/guardians to allow thier child to partiipate in all program activities and scheduled events.

Demographic Background

Foster Care: *

Yes

No

Participant has been enrolled in ACS Administration of Child Services *

Yes

No

Number of Individuals in their household *

Participant's Head of Household *

Single Parent

Two parents

Grandparent

First Name *

Last Name *

Email *

phone *

parent/guardian phone *

Address *

Apt, suite, etc.

Country

City

State

Zip code

Do you have internet and computer access at home *

Yes

No

What do you want to change about yourself? *

What is the BEST thing about yourself? *

I hereby give permission for my child to participate in the after school tutorial and virtual mentoring program V-ELMS. By committing my child to V-ELMS I acknowledge that I will encourage my child’s attendance to:

the after school sessions from 2:30 to 4:30 PM on Mondays and Thursdays
the Saturday Workshops and Trips with their MENTORS from 10:00 AM to12 noon
and the attendance at other scheduled TRIPS for their exposure.

As the Parent/Legal Guardian of my child, I hereby agree to the terms and conditions presented above. I am submitting this form to permit my child to participate in the V-ELMS’ program and all required program activities associated with V-ELMS for the agreed one-year contract. Sign and return this form via your child or to VELMS4u@gmail.com

DISCLAIMER

Since the mentee population is underaged, V-ELMS has put into place parental consent form. This form primarily gives the description of events provided by V-ELMS and asks parents/guardians to allow their child to participate in all program activities and scheduled events. You authorize your child be evaluated from the start of the program year and used in the context of evaluating the academic impact of the V-ELMS program. To understand that V-ELMS will use this information to investigate whether or not the program improves the academic performance of its student participants. To authorize V-ELMS to create and publish photographs, video, and audio recordings of my child, as well as written or recorded oral descriptions of my child. These materials may be used for educational research and promotional purposes only.

I have read and understand the description of events provided by V-ELMS and agree to allow my child to participate in all program activities and scheduled events. By signing this agreement, I acknowledge and agree that V-ELMS shall have no responsibility or liability for any harm, damages, losses, costs, expenses or other claims arising out of or in connection with any unsupervised contact between the mentor and my child, whether or not I have consented to and/or notified V-ELMS of such contact, and expressly waive any resulting claim against V-ELMS and release V-ELMS from any liability. In addition, I waive any claim against V-ELMS, and release V-ELMS from any liability in connection with any event sponsored by V-ELMS or any transportation to such event. I also authorize V-ELMS to create and publish photographs, video, and audio recordings of my child, as well as written or recorded oral descriptions of my child. These materials may be used for educational research and promotional purposes only. I understand that V-ELMS may revise, annotate, edit and otherwise alter the recorded material to emphasize certain aspects. The permission extends through the period of time the original project remains published. I understand that V-ELMS owns all copyright to these materials. I hereby release V-ELMS from any and all claims of any nature whatsoever which now or may hereafter have in connection with these recorded materials.

V-ELMS mission is to create a supportive environment that strengthens underserved students’ educational acumen to close the achievement gap, bridge the digital divide and promote social capital.

Mentee Registration Form

CONSENT

DISCLAIMER