Part B- Parental and Legal Guardian Consent Form (Residential

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Part B: Parental/ Legal Guardian Consent
Form for a Residential Internship Programme
Part A: should be completed by a member of staff at your school (either current or school you attended
before you were 16). They must be able to confirm your eligibility for an SMF programme.
Part B: should be completed by your parents or legal guardians to give consent applying to the
programme (s). You must complete the relevant part B form.
Please complete part A and the relevant part B (s) in block capitals and send this in by Friday 9th January
2015.
Both parts must be sent in to the ‘Social Mobility Foundation, 1st and 2nd Floor, 43-47 Leadenhall
Market, London EC3V 1LR’ Please write above the address on the envelope the programme(s) you’re
applying for.
The student who intend to participate in a residential internship must read the code of conduct below
and both the student and a parent/guardian must sign in the declaration boxes on the following page.
Without signing the form, the student will not be allowed to attend the internship.
Expected behaviour
Participants will be expected to show responsible behaviour throughout the two weeks and respect the
rights of other students, group leaders and colleagues in the department where you will be based.
Rules and regulations
For health and safety reasons, and in order for all students to have the opportunity to benefit from and
enjoy the internship, the following rules and regulations will be in operation:
● Alcohol must not be brought to the accommodation or place of work and may not be consumed
at any point during the two week period.
● The purchase or use of any illegal substances is strictly forbidden.
● Smoking is not allowed.
● Students are expected to attend all timetabled activities unless otherwise stated (exceptions will
only be made where there is a valid reason for absence, such as illness).
● Students are not allowed to leave the place of work or accommodation at any point during the
two week period without permission from appropriate staff members.
● Students are expected to follow any emergency procedure, such as a fire drill, as directed by
staff members.
● All first aid and medical emergencies should be reported to a group leader, supervising SMF
contact or department contact.
● Students are to look after the halls of residence and to maintain the furniture and fittings.
Accidental damage is to be reported to the group leader and to the administration office.
If damage is caused by negligence, unreasonable behaviour or vandalism, students will be
charged the full cost of repair or replacement.
● There will be separate male and female accommodation. Males and
females are expected to keep to their own accommodation areas.
● Students are expected to be in their rooms at specified times (which will be indicated on the first
day).
Parent/Carer Information
● The SMF takes no responsibility for contact between the participant and i) Organisations in
which he/she may be placed; ii) His/her Mentor(s); iii) Prospective supporters, which is not
formally part of the residential internship programme. Such informal contact includes meetings,
further paid/unpaid work placements and the exchange of personal details. It is the
responsibility of your child to disclose any such contact to you.
● In the event of serious incidents of misbehaviour, such as fighting, racial abuse or the use of
illegal substances, the student(s) concerned will not be allowed to continue on the internship
and arrangements will be made for the student(s) to be taken home.
● If I have any questions about the programme, I should email [email protected] or call
0207 183 1189. More information about the programme can be found at
www.socialmobility.org.uk.
● My child’s data and any information that my child has provided to the SMF will be processed in
accordance with the Social Mobility Foundation’s Privacy Policy, which can read at:
www.socialmobility.org.uk/privacy-policy
● I am happy with the information that my child has already provided the SMF in their application
with regard to his/her:
i. Medical conditions/allergies, of which the SMF should be aware in order to ensure
necessary provisions (this includes any medication and information needed for a medical
emergency)
ii. Disability
iii. Emergency contact details
iv. Consent for photographs in which he/she features, to be used in SMF media and
publicity
● I agree to my child receiving medication in addition to any emergency dental/medical/surgical
treatment as considered necessary by the medical authorities present.
● I understand that the SMF takes no responsibility for my child’s travel to/from the residential
internship. I understand that the SMF takes no responsibility for any loss or damage of my
child’s possessions over the course of this Programme.
● My son/daughter has the following dietary requirements: ___________________________
Please keep this Code of Conduct for your records
DECLARATION
To be completed by the student:
I have read the information in the Code of Conduct and if I am accepted I agree to adhere to the rules and regulations above. I
also agree to adhere to any additional rules and regulations explained to me during the two week period. I understand that I will
not be allowed to continue the internship or SMF programme in the event of serious misbehaviour on my part.
Name:
________________________________________________________________________________
Signed:
______________________________________________________________________________
To be completed by parent or guardian:
I am making a decision about allowing my child to participate in a residential internship programme, subject to him/her being
accepted onto it. My signature below indicates that I have read the information above and have decided to allow him/her to
participate in the Programme. If I wish to withdraw permission for my child to participate, I must inform the SMF in writing.
Name:
_________________________________________________________________________
Relation to student: __________________________________________________________________________
Signed:
_________________________________________________________________________
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