Parental Consent Form:

I understand, by submitting this form I am stating that I am the legal parent and guardian of the child I am submitting for and have the legal right and decision making privilege for that child. (Please submit a separate form for each child that is applying for a slot.) I confirm that my child:

 is a young women between the ages of 11-17.

 is focused on obtaining and maintaining good academic standing.

 demonstrates an interest and desire to be an active member of The Butterfly Effect, Inc.

 has the ability to commit to at least two days per month (usually Saturdays) for meetings and activities and it is my responsibility to get her there.

 is expected to follow all procedures and guidelines of the program, and I will work with the BE team to ensure they do.

 has submitted a written application.

Please complete the form below in its entirety and submit it with a copy of the child’s birth certificate.

Name

First Name

Last Name

Relationship to Child

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

School Child Attends

Child's Age

Current GPA

Child's extra curricular activities.

Child's Hobbies and Personal Interests

What do you hope for your child to gain from being a part of our organization?

What qualities do you believe a good mentor should have?

What do you feel your role in your child's participation entails?

Where you a part of any organizations growing up or are you currently?

Does your child have any allergies?

Does your child have any learning or physical limitations that would require special accommodations?

Please list any relatives that are prior or current participants in The Butterfly Effect, Inc program.