2. BOWIE YOUTH & FAMILY SERVICES CONTACT AND INFORMATION RELEASE FORM
   To Be Completed by the Parent/Guardian
4. Youth Name*
6. I hereby grant permission for Bowie Youth & Family Services (BYFS) Teen Mentor Program (TMP) to make contact with my child and conduct a personal interview for the purposes of applying to be a mentee. Staff may also make contact with my child on school premises for the purposes of screening and interviewing as well as ongoing support of his/her participation in the mentoring program.*

   1. Yes

   1. No
8. 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, mine and my child’s identity and other relevant information will be shared with the mentor to the extent it aids in facilitating a successful match.*

   1. Yes

   1. No
10. Photo Release: I grant to BYFS TMP, its representatives and employees the right to take photographs of my child and my property in connection with the above-named organization. I authorize its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that BYFS may use such photographs of my child with or without my name and for any lawful purpose, including such purposes as publicity, illustration, advertising, and Web content.*

    1. Yes

    1. No
12. By typing my name below, I acknowledge that I agree with the following statement:
    I am in full agreement with all above statements and give permission for my student to be assigned a mentor chosen by the Bowie Youth & Family Services Teen Mentoring Program team, and to work with the mentor who is matched with my child.
    
    If this form is submitted electronically, I agree that my typed name is the legal equivalent of my handwritten signature on this form.
    
    Parent/Guardian Signature*
14. Date*
    Date
Leave This Blank:


16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit Submit and Print

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