Permission Slip Release for EnvironMentors Dear Parent/Guardian: Please carefully read, and if you agree to the following terms, sign and return this letter. I, the undersigned, for valuable consideration, understand and acknowledge the following terms: My child will be in the care and authority of
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I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, wave, discharge and hold harmless (your university), and the National Council for Science and the Environment and its employees, from any and all claims, actions, or losses of property damage, body injury, loss of services, or otherwise which may arise out of my child’s participation on the I have read the above waiver and release and by signing it agree to its terms. It is my intention to exempt and relieve the (your university) and National Council for Science and the Environment from liability for property or personal injury. If you have any questions or concerns, please contact (Coordinator and contact information) _____________________________ Student’s Name
_____ Age
________________ Date
_____________________________ Signature of Parent or Guardian _____________________________ Printed Name of Parent or Guardian Emergency Contact Information: ________________________ Primary Contact Name
____________________________ Primary Contact Phone Number
________________________ Secondary Contact Name
____________________________ Secondary Contact Phone Number
Sample Authorization for Treatment Form
Authorization for Treatment
___________________________________ Student Name
________________ Date
As the parent/ guardian of the above named student, I hereby give authority to the staff of EnvironMentors to take my child to an emergency room of the nearest hospital should, for any reason, they require any minor medical or surgical treatment and/or medication while participating in an approved field trip activity. I further authorize the hospital and its medical staff to administer treatment as deemed necessary by them for the well-being of said student. I understand that staff will make attempts to notify me in all medical emergencies, and I will be contacted, if possible, for my permission if hospitalization or treatment of a serious nature is required. I have read and understand the above and I freely give my consent and permission of all things contained herein. __________________________________ Parent/Guardian Signature
___________________ Date
Media Release I grant permission for my child (name, voice, written work, video and photographic likeness) to be used by EnvironMentors and , ________ (name of University) and school personnel, for promotional purposes. Student’s name: ___________________________________________________________ Parent’s name: ____________________________________________________________ Parent’s signature: ____________________________________________ Date: _______
EnvironMentors is an initiative of the National Council for Science and the Environment 1101 17th St. NW Suite 250 Washington DC, 20036~ 202-530-5810~www.ncseonline.org
Release of FERPA Information to EnvironMentors The Family Educations Rights and Privacy Act (FERPA) is a federal law that requires schools, with certain exceptions, to get your permission before disclosing personally identifiable information from education records. EnvironMentors is a college access program that has a very high graduation and college acceptance rate amongst its students. In order to track that information, we need your permission to have _______________________ (Student's School) release: student name, address, telephone listing, diplomas and awards received, dates of attendance, transcript, graduation, and college acceptance information to EnvironMentors for the purpose of program evaluations and success tracking. NO PERSONAL INFORMATION ABOUT YOUR CHILD WILL BE MADE PUBLIC WITH THIS INFORMATION.
Student’s name: ___________________________________________________________ Parent’s name: ____________________________________________________________ Parent’s signature: ____________________________________________ Date: _______