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Girl Matters: It’s Elementary

Parent/Guardian Release Form



Parent/Guardian Nameyour full name
Girl's Full Nameyour full name
Schoolyour school name

I, [field7] the undersigned, do hereby grant or deny permission to the Delores Barr Weaver Policy Center for the following:

SECTION 1

To use the image of my child, [field1] and Their grade and age, as marked by my selection below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, voice recording, and/or video taken of my child and/or family for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the Delores Barr Weaver Policy Center’s website: www.seethegirl.org.

SECTION 2

To release information about my child’s individual needs to a referral agency such as (Full ServiceSchools, Girl Scouts) if eligible to receive additional services and supports to increase her success. This may include your child’s name, date of birth, needs she is demonstrating, as well as your contact information.

SECTION 3

To provide reporting information to the Florida Department of Juvenile Justice Prevention Web system (JJIS) on the demographics and needs of girls served through the It’s Elementary program as per grant requirements. All information will be confidential.

SECTION 4

To access the school records of my child and allow use of the information for grant reporting purposes in order to provide information including number of absences and suspensions of all girls served to funders such as (the Department of Juvenile Justice and The Remmer Family Foundation). All information will be kept confidential.

I acknowledge that I understand and agree with the Youth Rights Policy and Rights and Grievance Procedure provided to me by the Delores Barr Weaver Policy Center.

Dateof appointment
date_range
Parent/Guardian Nameyour full name
SignatureI agree to the terms and conditions
(Sign Here)
Clear Signature
I certify that I am the legal guardian of the above named girl.
Dateof appointment
date_range
Parent/Guardian Name
Phone Number
SignatureI agree to the terms and conditions
(Sign Here)
Clear Signature
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904-598-0901
40 East Adams, Suite 130
Jacksonville, FL 32202