PARENT/GUARDIAN Consent Form

Please complete the parent/guardian consent form below.

* denotes required field.

* Student First Name:

* Student Last Name:

* Parent First Name:

* Parent Last Name:

* 1. In what special activity(ies) does your student currently participate? (Please state the student's level of commitment as well as the length of the time the student has been involved in the various activities mentioned.)

* 2. Why would you like to see your student involved in The WEB?

* 3. Participating in The WEB is a serious commitment, both for the student and their families. Students are expected to fully participate. Do you see any challenges that will affect your family's ability to take full advantage of this program?

* 4. Please explain any personal characteristics in your family that should be considered when deciding whether the Du Bois Society should accept your student.

* 5. The Du Bois Society relies on its parent body to support its programs and activities and to make a financial and non-financial contribution in support of its mission. In what ways can we count on you to support our cause and the experience we offer your student?

* 6. Has your student ever been suspended or expelled from a school? If yes, please explain.

Completing the following statement constitutes the digital signature of both student & parent/guardian.

I give my student permission to participate in the 2010-2011 W.E.B. Du Bois Society program year. I understand the expectations and requirements of the program and I support them.

Parent/Guardian E-mail:

Parent/Guardian Confirm E-mail:

Parent/Guardian Phone:

Student E-mail:

Confirmation of completed form will be sent to both the Parent/Guardian & Student e-mail addresses. Follow-up phone calls to ensure the validity of consent forms may be made periodically.