LETTER OF CONSENT AND SCHOOL RECORDS RELEASE FORM

do hereby give my/our permission for my/our legal minor _________________________________, to participate in the Silicon Valley Future Stars Program, and any of its associated activities.

I/We understand that Silicon Valley Future Stars program is an integrated and innovative afterschool program that focuses on youth cultural awareness and educational enrichment programs that include career training in technology, broadcasting and performing arts. The program is operated by Silicon Valley African Productions (SVAP,) a non-profit San Jose based organization. So we use this enrichment program as an academic/civic commitment trap incentive, and innovation outlet/spotlight for paving a brighter future for the participants. The Future Stars program is to open to all middle and high school students in the Silicon Valley of California. However, the highest priority is given to the underserved, disadvantaged lower income, and lower achieving middle and high school students, in San Jose, who are at risk of dropping out of school.

I/we understand and accept that this Silicon Valley Future Stars opportunity is a good faith effort on behalf of SVAP to enhance the youths’ self esteem, and improve their positive image and academic performance through homework assistance, community involvement, publicity, television/media spotlights that will prepared them for high paying jobs in the future.

I/We agree that I/we will take full responsibility for getting my/our legal minor to and from each of these locations as deemed appropriate by SVAP.

I/We understand by signing this Letter of Consent, that I/we release SVAP of  San Jose, California, its successors, assignees, licensees and any other designees, from any medical, personal, or accidental liability regarding my/our legal minor’s participation in the Silicon Valley Future Stars program and any of its associated activities.

I/we consent to purchase any insurance required by the program site or school or nonprofit organization.

I/we the parent(s)/legal guardian(s) of_____________________further understand and agree that my/our legal minor will conduct himself/herself in a professional manner representative of the higher expections and standards set forth by SVAP.

I/we understand that as part of SVAP’s commitment to excellence, we are required to follow the performance and progress of our participants through their high school career. I/we understand that this signing this form authorizes my child’s school to release my child’s school records, which includes the student’s grades, teacher comments, standardized testing results, and/or psycheducational testing evaluations, to SVAP.

I/we hereby give permission to SVAP to have access to my child’s school records at this time or anytime in the future as needed and extend its validity from the date signed until completion of high school for tracking and reporting purposes.

I/we will abide by all terms and conditions set forth by Silicon Valley African Productions.

Signature of Parent(s)/Legal Guardian(s)

Name: ________________________ Signature:_____________________ Date_______________

Name: ________________________ Signature:_____________________ Date_______________

Student’s Current School: _______________________________________________________________________

                                                                     Name                                                                Address

Thank you for your interest.  You MUST fill out and sign the registration form; read and sign the Program Policy and Procedure; and complete and sign Media Authorization/Release form to complete the registration.