Legal Guardian
• • •
PARENT AUTHORIZATION & AGREEMENT To be completed by a custodial parent or legal guardian
I, parent or legal guardian of the applicant, hereby gives permission for my child to participate in MESA activities conducted by the
CSU Chico MESA Center and the University of California. I understand that my child’s enrollment is dependent upon satisfying the
program eligibility criteria. I further understand that the primary intent of the programs is to motivate, support and prepare
students for admission and success in postsecondary education. With my signature below:
I agree to:
Actively and enthusiastically encourage my child to prepare for, and seek, a university education
Support my child’s participation in services and activities that promote achievement, college-readiness and career exploration
Participate in MESA parent activities or workshops offered throughout the year
I authorize MESA program directors, staff and their assistants to:
1. To have access to, and receive copies of, my child’s school records through the completion of 12
th
grade including progress
reports, grades, transcripts, and standardized, CAHSEE, SAT and ACT test scores. I understand that information will be kept in
strict confidence and will be used to: a) monitor my child’s academic progress; b) establish program eligibility; and c)
determine when additional support services are needed.
2. To disclose information from my child’s academic records to designated representatives of their colleges and universities so
they may determine my child’s eligibility for admission at their institutions, his/her need for special services and for general
use in planning outreach and recruitment activities. These records will be maintained by the CSU Chico MESA Center and the
University of California consistent with the Federal Family Education Rights and Privacy Act of 1974, applicable state laws and
university policies.
3. To allow my child to attend field trips and events sponsored and coordinated by MESA. I understand that my child will have
adult supervision while on these field trips.
4. To take and use my child’s name, quotes, photographs, drawings, audio clips, or other visual/audio images, and associated
written descriptions, in MESA press releases, publications, websites, promotions, posters and presentations. These may be
used without further notification or approval, and understand that there is no compensation or claim to the finished product.
Medical Release
Should medical attention be required while participating in a MESA event or activity, I give consent for my child to receive medical
examination and treatment, including x-rays, drugs, surgery, or emergency medical services, as may be deemed necessary by the
attending physician or medical personnel. In an emergency situation, I understand that staff will attempt to contact me for
guidance, but if inaccessible, I authorize the attending medical personnel to act with their best medical judgment. I further agree
that any cost incurred for these medical services will be solely my responsibility.
I further release MESA, CSU Chico, the Trustees of the California State University, and the University of California from any liability on
account of injury to or death of my child arising out of my child’s participation in program activities and hold them harmless for any
damage or costs that may be incurred due to the acts of my child’s participation in these programs. In addition, I agree to assume
full responsibility for any risk of injury, death, or property damage arising out of my child’s inappropriate behavior while on a MESA
activity.
I understand that this consent may be withdrawn at any time by my written instructions to the CSU Chico MESA Center.
I have carefully reviewed this agreement, agree to the terms outlined, and hereby certify that all the information provided on this
application is accurate to the best of my knowledge.
Parent’s/Legal Guardian’s Signature Date
PRINT Authorizing Parent’s/Legal Guardian’s Name:
Father Mother
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