|
Village -to-Village
A nonprofit
organization that combines Cultural Awareness and
Community
Responsibility
using Mentoring, Youth Leadership, Education & Arts
Authorization to
Participate in
The
"Village-to-Village" Gatherings
Please complete this
authorization form and return it to David Thompson
Youth Name:
________________________________________________________
Address:
____________________________________________________________
City/State/Zip:
_______________________________________________________
Telephone:
_________________________________________________________
School:
_____________________________________________________________
Grade Level:
_________________________________________________________
Age:
_______________________________________________________________
Food/Other Allergies:
_________________________________________________
I hereby give permission for my
son/daughter _______________________________
to participate in the "Village-to-Village"
Gatherings and Mentoring Program. This form verifies
that the aforementioned child
can and will attend gathering provided they display good
behavior
and respect for others and
themselves.
I understand that
Village-to-Village or I may withdraw my son/daughter
from the program
at any time and for any reason,
without notice. By signing this form, I also agree to
share my personal contact information with the
organization and authorize use of my or my child’s image
in photos taken during
Village-to-Village events for display on the
organization’s website, in brochures, publications, etc.
without remuneration or further authorization.
Youth participating in the
program may attend events that are culturally-related,
educationally enlightening and fun with
Village-to-Village outside of regular meeting locations.
At such events students must remain under the direct
supervision of the adults present at all times.
___________________________________
___________________________________________________
(Parent/Guardian name – print)
(Parent/Guardian signature)
Contact Information
Home: __________________
Work: ___________________
Mobile: __________________
Email address:
_______________________________
www.thevillagetovillage.com
● 267-992-6262 ● 267-978-1082
|
