Student's Name: ____________________________________________________

School:  __________________________________________________________

Grade:  __________________________________________________________

Teacher:  _________________________________________________________

Name of Parent or Guardian:  __________________________________________

Home Phone:  _________________

Emergency Phone (during math sessions):______________

Email Address: _____________________________________________________

I give permission for my child to attend the Math Homework Help sessions, held at Van Wyck Junior High School, on one or more of the 2007-2008 session dates.

I understand that I am responsible for transporting my child to and from the help sessions.

I give permission for the help session organizers to reach me at the above numbers in an emergency, including the need to pick up my student.

I have discussed the following items with my child and we have agreed that he or she will:

• Let me know when he or she is planning to attend a session.
• Follow instructions from the adult volunteers in charge of the sessions.
• Stay in the assigned room at school after his or her homework is done, and while waiting to be picked up.

Signature of parent or guardian: ________________________________________

Date: ________________________________________