Please fill out the Parental Consent form below

This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their child to participate in our Program.

Student *
Parent 1 *
Parent 1
Parent 2
Parent 2
Relationshp to Student *
Parent's Phone *
Parent's Phone
Emergency Contact *
Emergency Contact
Emergency Contact's Phone *
Emergency Contact's Phone
Emergency Contact's Address *
Emergency Contact's Address
Please Answer The Next Section As Complete & Carefully as possible
Before Submitting This Form, Please Agree to the Following Statements
I have read through the CSMP info and understand what my child is signing up for *
I understand that both CSMP Student and Parent Applications will be confidential and will be used to determine who will be the right match for my child. I also understand that if there are any questions or concerns I will be notified. I also understand that the Director and Advisor are available for me to talk with if I should have concerns or questions. *
I give my student permission to fill out the Application for the Crosspoint Student Mentorship Program *
I understand I need to be at the “First Meeting” and will do my best to be there. *
It is mandatory that parents be there for the “First Meeting” when their child meets their mentor. We feel it is very important that a parent meet the person who will be mentoring their student. This meeting should only take 15 minutes.