PERMISSION FORM & RELEASE FOR PARTICIPATION IN RESONANT
VIBE
By confirming below, I, as the legal guardian, give full
permission:
- For my child to participate in the Resonant Vibe Program.
- For the volunteer matched with my child, who has been
screened and approved by Resonant Vibe, to transport my child to events and
match activities.
- For the school to provide social and academic information
about my child to Resonant Vibe (e.g. report cards, behavior reports);
- To have my child participate in an in-take interview
conducted by Resonant Vibe staff and complete questionnaires throughout his/her
time in the program containing questions about school, home life, and personal
interests.
- To have my child talk with a Resonant Vibe staff person
about personal safety.
- For Resonant Vibe staff to provide contact information for
me and my child to the volunteer.
- For Resonant Vibe staff to meet with my child at their
school and/or afterschool program center to conduct an interview and/or match
support.
- I give permission for my child’s Mentor to meet with them at
their school.
I understand that the program is not obligated to match my
child with a volunteer and that as part of the enrollment process, I will be
asked to provide additional information through an in-person interview.
I
understand that the information I provide in the enrollment process will be
kept confidential unless disclosure is required by law and with exceptions
noted.
I understand that incidents of
child abuse or neglect, past or present, must be reported to proper authorities.
I understand that certain relevant information about my child will be discussed
with the volunteer who is a prospective match (i.e., demographic information,
information relevant to volunteer preferences, and information relevant to
child-safety and well-being).
I certify that all of the information on this form is true
and correct and that all income is reported. I understand this information is being given for the receipt of federal
funds, that the information on this application may be verified, and that
deliberate misrepresentation of the information may subject me to prosecution
under applicable state and federal laws. I understand this information will not
affect my family's qualification for the program.
I do hereby release the organization and its employees,
agents, members, volunteers, and all other persons on its behalf from any and
all liability for any damage or injury which such child might sustain while
participating in said program and activities, including but not limited to any
liability to any right of action that may occur to such child directly, or to
me as their guardian. I understand that this information may be shared with
the school or with partnership agencies when applicable.
If my child is matched with a Mentor, I agree to support my
child’s match by reviewing the program and safety information given to me by
Resonant Vibe, communicating with Resonant Vibe staff as outlined in
expectations (which includes communication at least once a month), and immediately reporting any concerns I might have to
Resonant Vibe staff.