2011 RSSP Parental Consent and Receipt Form by wuzhengqin

VIEWS: 5 PAGES: 1

									                                                                                 Revised 7/10

Parental Consent and Receipt
MPW Regional Safe School Program


Student Name                                       School Year                     Grade Level

I. Please check the appropriate spaces to indicate your permission for your child’s
   involvement for each of the items below.


                    I give permission for my child to be photographed and/or videotaped
 YES        NO      during RSSP activities. I also give permission for my child’s picture/video
                    and/or name to be used in positive informational news coverage and for
                    educational purposes.

                    Since classes may take field trips or community based walks as part of
 YES        NO      the Program’s activities, I give permission for my child to be transported
                    and/or leave RSSP grounds for these purposes.

                    I give permission for my child to use the Internet at school in accordance
 YES        NO      with the RSSP Computer/Internet Acceptable Use Policy.

______    ______    I give permission for my child to watch PG-13 movies.
  YES       NO

______    ______    I give my child permission to participate in lessons and activities offered
  YES       NO      by community providers who work with and support the RSSP.

II. Please check the appropriate spaces to indicate your receipt of each of the items
    below.


                    I have received a copy of the current MPW Regional Safe School Program
 YES        NO      Handbook, which is contained within the registration materials. I under-
                    stand that it is my responsibility to read and review it with my child.


                    I received a copy of the MPW RSSP Computer/Internet Acceptable Use
 YES        NO      Policy when my child first enrolled in the Regional Safe School Program.


By signing this form, I hereby give my permission for the items checked “yes” in
Section I, as well as acknowledge receipt of the items checked “yes” in Section II. I
understand that this is for the duration of the current school year, and that I may
rescind this permission by contacting the Program Director in writing.


                                                          ______                   ___________
Parent/Guardian Signature                                                 Date

______________________________________________________                    _________________
Parent/Guardian Signature                                                 Date

								
To top