Dear Parent or Guardian:

Your child,   ____________________________, has been referred to the school’s Middle School Graduation Coach in order to receive additional support services to enhance your child’s educational experience.  Your permission is needed for your child’s general participation in activities designed to increase school attendance, improve learning, encourage personal and social development and increase employability skills. Support services and enrichment experiences will help to meet your son/daughter's academic and human service needs. Please review and sign this form demonstrating agreement and granting authorization for your child's participation.

A.   I, _____________________________, hereby grant permission for my child, _________________________________, to participate in additional support services.  I  
      specifically authorize:

1. Participation in interviews for student and program evaluation purposes.
2. Release of confidential information by appropriate school staff to qualified personnel as needed (grades, attendance, discipline, health, etc.) and authorize the use of I-Parent by the Graduation Coach for use to keep track of this information. I understand that under federal and state law, this information will be kept in confidentiality.
3. Participation in services specified in my child’s Peach State Pathway Plan, which may include counseling, tutoring, instruction, and cultural enrichment.

B.  To further my child's academic, personal, and vocational development, I will participate in parent activities.

C. Indicated below are specific activities in which I do not wish my child to participate: ___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Please sign the form below and have your child return to his/her homeroom teacher. If you have any questions, please contact me at 706-695-7448.

Thank you,

Kelley-Marie Sierra

Graduation Coach, Gladden Middle School

Parent/Guardian Signature: ______________________________________________________             Date:  ____________________

Note: All volunteers, staff, and contracted personnel must adhere to policies set forth by HIPAA (Health Insurance Portability and Accountability      Act, 1996).  This provides the safe guarding of each individual’s personal health information.