Facebook
Twitter
Instagram
You Tube
Search the site
Menu
Home
Status of Girls
About Us
Mission
Board & Leadership
Staff
Our Story
Accomplishments
Media Library
Position Statement
What We Do
Research
Advocacy
Training
Programming
Contact
Get Involved
Donate
Make a Referral
Parent/Guardian Release Form for GMIE
Please enable JavaScript in your browser to complete this form.
Parent/Guardian Name
*
Girl's Full Name
*
School
*
Grant or Deny Permission
I, the undersigned, do herby grant grant or deny permission to the Delores Barr Weaver Policy Center for the following:
Section 1
*
I grant permission to use my child’s image in the above mentioned capacities.
I deny permission to use my child’s image at all.
To use the image of my child, 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
*
I grant permission to release my child’s information if eligible for additional services.
I deny permission to release information.
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
*
I grant permission to use my child’s information for research and reporting as described below.
I deny permission to use my child’s information for research and reporting as described below.
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
*
I grant permission to use my child’s information for research as described below.
I deny permission to use my child’s information for research as described below.
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.
Date
*
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.
Parent/Guardian Full Name
*
Phone Number
*
I certify that I am the legal guardian of the above named girl.
*
Yes
No
Signature
*
Clear Signature
Name
Submit
Parent/Guardian Release Form for GMIM & Groups
Please enable JavaScript in your browser to complete this form.
Parent/Guardian Name
*
Girl's Full Name
*
School or after school program
*
Grant or Deny Permission
I, the undersigned, do herby grant grant or deny permission to the Delores Barr Weaver Policy Center for the following:
Section 1
*
I grant permission to use my child’s image in the above mentioned capacities.
I deny permission to use my child’s image at all.
To use the image of my child, 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
*
I grant permission to release my child’s information if eligible for additional services.
I deny permission to release information.
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
*
I grant permission to use my child’s information for research and reporting as described below.
I deny permission to use my child’s information for research and reporting as described below.
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
*
I grant permission to use my child’s information for research as described below.
I deny permission to use my child’s information for research as described below.
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.
Date
*
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.
Parent/Guardian Full Name
*
Phone Number
*
I certify that I am the legal guardian of the above named girl.
*
Yes
No
Signature
*
Clear Signature
Email
Submit
Referral Form for GMIC or Open Doors
Please enable JavaScript in your browser to complete this form.
Name of the person/agency making the referral
*
Phone
*
Email
*
Referred Person's Name
*
Referred Person's Race
*
Referred Person's Gender
*
Date of birth
*
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
YYYY
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Date / Time
*
Referred Person's Contact Information
*
Parent/Guardian Name and Contact Information
*
Is the person involved with Juvenile Justice System?
*
Yes
No
Unknown
Any other community organization(s) involved with the person?
*
Please briefly describe the reason for seeking services with the Delores Barr Weaver Policy Center? Which services are you interested?
*
Currently enrolled in school? If yes, where and last grade completed?
*
How did you hear about the Delores Barr Weaver Policy Center?
*
Comment
Submit
Search
↑