LATM Parent/ Guardian Release Form
I, as the parent/guardian of the student applicant, understand LATM’s out of school time programs, and recognize that all programs will involve activities, which will be conducted both on and off campus of the Los Angeles Unified School District (LAUSD), Green Dot Public Schools, and Alliance for College-Ready Schools. In order for my child to participate in both in person and virtual activities, I understand, grant and fully authorize the following:
- I give my informed authorization and permission for my child to participate in all LATM programs;
- Including, but not limited to, LATM’s e-Mentoring experience via an interactive videoconferencing platform. Interactive e-Mentoring classrooms enable students to see, hear and speak to mentors such as teachers, college students and business professionals from the home environment. In order for your child to specifically participate in videoconferencing, LATM requires your written permission.
I understand that in E-Mentoring Classrooms (videoconferencing room) my child’s voice, physical presence, and participation in mentoring activities will be transmitted to distance learning sites.
- In order for my child to participate off campus activities, prior to each activity, I will receive a notice or application granting me the opportunity to allow or withhold my permission for my child to participate in that specified activity;
- I give my authorization for LATM to obtain appropriate emergency medical or dental attention for my child if such attention is required, at any time when I am unavailable, for contact at the numbers on the student application and hereby release LATM from any liability that might arise from receiving medical attention;
- I give consent to the disclosure of personally identifiable information from my child’s education records under the Family Education Rights and Privacy Act and allow for LAUSD, Green Dot Public Schools, Alliance for College-Ready Schools to disclose such information to LATM; and I give consent for LATM to access my child’s current, past and future records such as grades, attendance, achievement scores, and high school graduation data, etc.
- I give permission for my child to participate in program evaluation surveys and understand I may be required to participate in an occasional program evaluation. I give consent for my child to participate in surveys designed to evaluate the effectiveness of LATM’s programs and activities. LAUSD, Green Dot Public Schools, Alliance for College-Ready Schools does not sponsor, authorize or have any connection with this survey;
- The LATM mentoring staff, at times, may need to access and share information with mentors and other parties to help improve program effectiveness and or to help reinforce or sustain quality mentoring relationships;
- I fully authorize and grant LATM, its supporters and all persons or entities acting for or through LATM the right to print, photograph, reproduce, record, and edit, as desired, my child’s image, name or likeness, written statements and/or voice on audio, video, film, slide, public affairs releases, recruitment materials, public service announcements, documentaries, on-line and web publishing, or any other electronic or printed formats (“released property”) currently developed or which may be developed to increase public awareness, training, educational purposes, and for research through the use of mass media, displays, brochures, websites, and other means of communication; LATM may authorize any third party, to use and or publish released property in any document, video, publication, or other communication created or issued by LATM or the third party, regardless of whether published by LATM or the third party and regardless of whether published in print, video, audio, electronic or other formats. LATM, in its sole discretion, will decide whether to use or publish released property
I give permission for my child to be filmed, recorded or photographed. I understand that all film, including digital images and photos are the sole property of LATM, and may be used in displays, or other electronic/audio formats to the public, to publicize the program, or for printed materials published by and/or for LATM and understand, LATM in its sole discretion, will decide whether to use or publish released property.
- I understand and agree to have my child follow all LATM mentoring guidelines and understand that any violation on my child’s part may result in suspension and/or termination of the mentoring relationship;
- I agree to be flexible and participate in positive discussions with my child to support my child in succeeding in LATM’s programs;
- I agree to picking up my child at the designated closing time of the program as well as at the conclusion of all fieldtrips;
- I understand LATM reserves the right to dismiss my child from the program at any time for any reason.
I understand the application and parent release form is intended as a means of informing and gaining the consent of the parent/guardian to allow their son/daughter to participate in Los Angeles Team Mentoring’s Programs as described above.
I understand that my child will be participating in various activities with one or more mentors and that my child will be under the supervision of his/her mentors during these times. I agree and hereby release from liability the Board of Education of the City of Los Angeles, LAUSD, Green Dot Public Schools, Alliance for College-Ready Schools, and LATM and any person acting on their behalf, from any and all liabilities, claims, demands or causes of action whatsoever that I may have as the Parent or Guardian of this child for any injuries to the person or property of the LAUSD, Green Dot Public Schools , Alliance for College-Ready Schools or other harm caused at any time during participation in LATM, as a result of his or her own conduct, the conduct of other participants, the conduct of the above-named school, LATM, or any person acting on their behalf or the conduct of any other person.