Sample contact and information release

1. Sample Contact and Information Release
(Note: Form to be completed by the parent/guardian or mentee if the mentee is under 18 years of age.
This form may not be needed if permission to participate is requested on the general YouthBuild
application.)
[Program] Participant: __________________________________ Date: ________________
School: _________________________________________________________
I authorize _______________ to obtain any needed information regarding my son/daughter from his/her
school’s staff, including academic and behavioral records and conversations with teachers, counselors,
and other administrative staff. I authorize the program to interview my son/daughter for the purposes of
matching them with an appropriate mentor. I also authorize any additional information gathering and data
collection for the purposes of program evaluation and assessment, including the administration of surveys
and participation in interviews and focus groups.
Further, I understand that basic information about my child will be anonymously (without names) shared
with a prospective mentor(s) to aid in determining a suitable match. Once a mentor/mentee match is
determined, my child’s identity and other relevant information will be shared with the mentor to the extent
it aids in facilitating a successful match.
____________________________________________ _______________
Parent/Guardian/Mentee Signature Date
Parent/Guardian/Mentee Name:
____________________________________________________
Address______________________________ City_____________ State____ Zip_____