Parent/Guardian Permission Form Student must have permission form on file to participate in the college visit.
In-Person College Visit | Tuesday, April 2nd | NC A&T State University & NC Central University 8:45 a.m. – Check in @ Crosby Scholars office, 2701 University Parkway, Winston-Salem, NC 27105 • Please arrive by 8:45 a.m. The bus will depart promptly with or without you. 10:00 a.m. – Campus visit at North Carolina A&T State University – Lunch provided by Crosby Scholars Program 1:30 p.m. – Campus visit at North Carolina Central University 4:30 p.m. – Pick up @ Crosby Scholars office, 2701 University Parkway, Winston-Salem, NC 27105 • Please have a ride arranged for 4:30 p.m. when we return to the Crosby Scholars office.
I give my student, _____________________________________ (STUDENT NAME), a student at _________________________________________ (HIGH SCHOOL NAME), permission to participate in the Crosby Scholars College Visits on the date marked above. I understand that I am responsible for providing transportation to and from the Crosby Scholars office. Further, I understand that it is my responsibility to arrange transportation for my student to be picked-up at the designated time, thereby releasing the Crosby Scholars staff of the responsibility of supervising my student after the conclusion of the program (4:30 pm). In the case of an emergency, I authorize the Crosby Scholars staff to seek the appropriate medical treatment for my child. I hereby release the Crosby Scholars Community Partnership, Goodwill Industries, North Carolina A&T State University, North Carolina Central University, and the transportation provider of any liability in the event of accident or emergency. In case of emergency, please contact (name) __________________________________ at (phone #) ______________________________. I have listed my child’s special medical conditions below: ________________________________________________________________________ ________________________________________________________________________ Parent Signature: ______________________________ Date: _____________________ Please physically or digitally sign above- a typed name will not qualify as a signature. Parent Email: ___________________________
Parent Cell #: ______________________
By providing your cell #, you agree to receive text message reminders.
Return form via email, fax, or text to:
Senior Program Team | seniorprogram@crosbyscholars.org | 336-725-1321 (fax) | 336-671-5494 (cell) The Crosby Scholars Community Partnership | 2701 University Parkway, W-S, NC 27105