Parent Authorization
You play a very important part in the success of our mentoring program. Please complete the following questions. This information will help us to properly match your child with a mentor.      
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Email *
Name of youth   *
First Name, Last Name
Parent or Guardian Name *
First Name, Last Name
Email *
Phone # *
How well does your child do in school ? *
1 being the worst
5 being the best
Describe your child’s personality (outgoing, introverted, shy, friendly, confident, stubborn, etc.)
Column 1
Outgoing
Introverted
Shy
Friendly
People pleaser
Confident
Stubborn
Easily influenced
Other
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What do you hope your child will gain from having a mentor? *
Are there any factors that would prevent your child from participating in this program (transportation, babysitting, employment, health or any other responsibilities)? *
Does your child have any health concerns ( ADHD, ADD, Asthma, food allergies, etc. ) *
NOTIFY IN CASE OF EMERGENCY Name / Relationship / Phone Number
I have read and understand the information given to my child about Rooted Ones Mentor Program. I hereby give my permission for my child to participate in this program. I will assist my child in keeping all appointments with his mentor. I will attend all parent events and I agree to communicate with the Mentor Coordinator regarding any concerns I may have about my child’s participation in the Rooted Ones Mentor Program. I also understand that I will be given the opportunity to meet my child’s mentor. I also understand that my child will occasionally meet with his mentor at scheduled events held at the school or in the community. All meetings between my child and his mentor held outside of the school setting, and not supervised by the Mentor Coordinator, shall be arranged by my child, the mentor, and me and I take full responsibility for such meetings. *
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