Sample Parent/Guardian Consent

Name of Participant:

Parent/Guardian Name:

Parent/Guardian Postal Address:

Parent/Guardian Email Address:

Parent/Guardian Telephone Number(s):

I wish to participate in the [program name] online community. I have read the Protégé Guidelines, understand the information presented, and agree to the conditions for participation.

Signature of Participant and Date: ______________________________/____________

I have read the Protégé Guidelines, understand the information presented, and give permission for _____________________ [participant name] to participate in the [program name] online community. I understand that it is my responsibility to supervise my child's use of the Internet and enforce safety guidelines such as Kids' Rules for Online Safety, published at SafeKids.com, www.safekids.com/kids-rules-for-online-safety.

Name of Parent/Guardian: _________________________________________________

Signature of Parent/Guardian and Date: ___________________________/_________