EmailMe Form - Learning Bridge Program—Parent/Guardian Consent

Student Information

Complete the following student information.

Student Name *

First Last

Student Date of Birth *

MM / DD / YYYY

What school does your student attend? *

For Elementary school students:

Who is your student's primary teacher?

For Middle/High school students:

Who are your student's teachers in the subjects for which they need greatest support?

Select the last grade that your student completed *

Does your student have any food allergies? *

No

Yes (list them)

Does your student have any dietary restrictions? *

No

Yes (list them)

Does your student have any other allergies? *

No

Yes (list them)

Is your student allowed to participate in activities? *

No

Yes

Parent/Legal Guardian Information

Complete the following parent/legal guardian information.

What is your relationship to the student? *

Parent

Legal Guardian

Name *

First Last

Email *

Phone *

### - ### - ####

Parental Consent Statement

As the parent/legal guardian, I certify that my student has my permission to participate in the Learning Bridge program. I understand and also agree that my student will follow the instructions of the Bridgebuilders and will treat other students/adults with courtesy and respect. I also give CHCCS permission to collaborate with the Learning Bridge Program to share general academic performance information that would help inform the work of the Bridgebuilder who is supporting my student.

Signature *

Clear

Today's Date *

MM / DD / YYYY