Case Manager Permission Form for Mentor Tutor Program



Arizonans for Children, Inc.

To Be filled out By DCS Case Manager

Mentor Tutor Consent for Contact and Release of Information and Liability

NOTE: Consent form must be signed by case manager before child can be  matched with a tutor/mentor.

I, , the Case Manager for , do hereby grant permission for AFC Tutoring/Mentoring  Program to make contact with the above named child and conduct a personal interview for the purposes of applying to be a mentee.  AFC may also make contact with the above named child on school premises for the purposes of screening and interviewing as well as ongoing support of his/her participation in the Tutoring/Mentoring  program and will be allowed access to the CPS files and school records on the child.

I understand that basic information about the above named child will be anonymously (without names) shared with a prospective mentor(s)  to aid in determining a suitable match. Once a match is determined, the above named child and caregiver's identity and other relevant information will be shared with the mentor to the extent it aids in facilitating a successful match.

I agree to have the above named child follow all Tutoring/Mentoring  program guidelines and understand that any violation on the above named child’s part may result in suspension and/or termination of the Tutoring/Mentoring relationship.

I do hereby give my consent for the above named child to participate in all activities and events sponsored by AFC and to be allowed to leave the group home, shelter, or foster home for tutoring sessions, outings, activities, and visits with the AFC staff members and/or volunteers listed below. I also give my permission for said staff members and/or volunteers to meet with the child's teacher(s) and/or guidance counselor, and for the release of school/educational, medical, and mental health care records.

I hereby acknowledge that the above named child will be transported b y his/her mentor while participating in the AFC Tutoring/Mentoring Program, and that such transportation is voluntary and at his/her own risk.

I understand that, while every effort is made to ensure the health and safety of each participant, some outdoor activities (hiking, backpacking, camping, etc.) can involve risk and may result in injury. I therefore give my authorization for treatment in case of injury to the following AFC staff members and/or volunteers: ____________________________ Child's Tutor/Mentor.

I release the AFC Tutoring/Mentoring  of all liability of injury, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any AFC mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.

Signature of DCS Case Manager:
Your Email:
Date:

Select application recipient: