SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

555/555-1234

GIFTED AND TALENTED PROGRAM

PARENT PERMISSION

Participation in any program or service offered for gifted students is voluntary on the part of the students and requires written permission of their parents or legal guardians.

Please indicate your wishes regarding placement of your child in the Gifted and Talented Program by checking the appropriate space provided below.

______I do wish for my child, ____________________________to participate in the XYZ Charter Gifted and Talented Program.

______I do not wish for my child,____________________________ to participate in the XYZ Charter Gifted and Talented Program. I understand that if at a later date I want my child to enter the GT Program, he/she will have to re-qualify.

_________________________________________ ___________________________

Parent Signature Date

Please Print:

___________________________________________________________________________

Please print parent’s name

__________________________________________________________________________________________

Current street address

__________________________________________________________________________________________

City, State, Zip

__________________________________________________________________________________________

Home Phone Work Phone

Date received by the Charter_________________________________________________________________

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