Student Mentor Consent Form

Student Mentor Consent Form

This Student Mentor Consent Form documents voluntary participation in a supervised mentorship relationship facilitated by the educational institution. Completion of this form constitutes consent to the terms, acknowledgments, and authorizations stated below.

Student Information

Student Name:

Date of Birth:

Student is 18 years of age or older:   If not, parent/guardian information is required below.

Parent / Guardian (if student is minor)

Mentor Information

Program Details and Schedule

Anticipated Start Date:

Anticipated End Date:

Consent, Authorizations and Acknowledgments

Consent to Participate: I hereby consent to my participation (or consent on behalf of the minor named above) in the mentorship program described in this form. I understand that participation is voluntary and may be terminated by either party upon written notice. Consent covers routine mentorship activities, academic guidance, and career counseling conducted by the named mentor and approved program staff.

Access to Academic Information: I authorize the institution to share the student’s academic and attendance information limited to records reasonably necessary for the mentor to provide effective guidance. This authorization is limited, revocable in writing, and does not waive statutory protections where applicable.

Background Screening: Mentors are required to undergo background screening and any required clearances. By signing, I acknowledge that the institution may verify the mentor’s clearance status and that participation requires compliance with institutional screening policies.

Confidentiality and Mandatory Reporting: Mentor and student interactions are expected to be treated with respect for confidentiality. Confidentiality does not apply to disclosures that are required by law or institutional policy, including but not limited to reports of abuse, threats to safety, or other mandatory disclosures.

I consent to the release of the student's limited academic records (grades, attendance summaries, and progress notes) to the mentor for the duration of the mentorship relationship.

I authorize the use of photographs or video including the student for program-related educational and promotional purposes, subject to institutional review and without financial compensation.

Emergency & Medical Information

Authorization for Emergency Medical Treatment: I authorize institution personnel to seek emergency medical treatment for the student if necessary. I understand that reasonable efforts will be made to contact the emergency contact before treatment when feasible.

Risk, Liability and Termination

Risk Acknowledgment: I understand that participation in mentorship activities may involve routine risks associated with meetings and travel for program activities. I accept responsibility for instructing the student regarding personal safety and understand that the institution maintains policies and procedures intended to mitigate risks.

Termination: Either party may terminate the mentorship relationship at any time by providing written notice to the program coordinator. Termination does not relieve either party of obligations accrued prior to termination.

Acknowledgment and Certification

By signing below, I certify that the information provided on this form is true and complete to the best of my knowledge. I acknowledge that I have read and understand the policies and consents set forth herein, and I agree to abide by the program rules and applicable institutional policies while participating in the mentorship program.

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