Provost Scholars Permission Forms 2025-2026

Parent/Guardian Acceptance Letter

Dear Parent(s) or Guardian(s):

Case Western Reserve University (CWRU) is happy to inform you that your child has been selected to become a Provost Scholar for the 2025-2026 Academic Year. The mission of the Provost Scholars Program is to improve the academic outcomes of middle and high school scholars. The program is designed to engage volunteer CWRU faculty and program team members in community-building with scholars by embracing education, academic achievement, skill development, hard work, emotional intelligence, and perseverance as the centerpiece of their future. Through mentoring, tutoring, networking, and relationship building with CWRU faculty, your scholar will have the opportunity to explore educational pathways and career options.

The Provost Scholars will visit the CWRU campus twice each week where they engage in one-to-one mentoring, university seminars, tutoring, workshops, and other creative learning activities, such as field trips in local and regional geographical areas.

Your son/daughter will also be matched with one faculty member at CWRU. Twice weekly, your scholar will interact with program team members, mentors, and tutors for the duration of the afternoon. E-mails, texts, social media, and other similar forms of communication will be used to encourage contact between and among the scholars, parents/guardians, program team members, mentors, tutors, and stakeholders. You will receive a profile of your Scholar’s mentor. You will be expected to meet your Scholar’s mentor during planned activities, and other program-based opportunities to interact with team members, mentors, and tutors.

In addition, to help facilitate the academic and social/emotional development of the Provost Scholars, we are requesting that you give permission to program team members and mentors at CWRU to have access to your scholar’s academic grades, attendance data, teacher/counselor comments, and other documents. These data will be confidential and private and used exclusively to assist your Provost Scholar. Also, the data will be stored in an electronic medium that is encrypted and password protected. Before mentors can have access to these records, they will have completed an orientation and training program conducted by the Provost Scholars team members.

Furthermore, we are requesting that you participate in the Parents’ College at Case, which convenes on the second Saturday of every month, (September 2025-April 2026), from 10:30 am to 12:00 pm. The purpose of the Parents’ College at Case is to provide opportunities for parents/guardians to learn about additional information that is important for enhancing the academic and social/emotional aspects of the Provost Scholars. Parents/guardians will help to determine the content that will be featured at the College.

The first sessions will include a detailed orientation about the program and its requirements. If you agree that your son/daughterhas your permission to participate in the Provost Scholars Program, please read, sign, and return the following forms.

Sincerely,

Dr. Faye Gary, Professor, Program Director, Provost Scholars Program

Dr. Lee Thompson, Professor, Associate Program Director, Provost Scholars Program
Ms. Latonya Shazor, Assistant Director, Provost Scholars Program
Ms. Kate Burleigh, Program Manager, Provost Scholars Program

The Provost Scholars are in the Relentless Pursuit of Excellence.

Parent/Guardian Permission Form

My daughter/son has my permission to participate in the Provost Scholars Program at CWRU which will necessitate that he/she interact with a mentor once a week, participate in tutoring sessions, workshops, field trips, weekly seminars. and other activities that occur on the CWRU campus and a variety of designated sites. I understand that the program may pivot to being conducted virtually or possibly cancel sessions at any time.

The Provost Scholars are scheduled to travel to CWRU twice a week. As a rule, they will meet with faculty mentors on Tuesdays where they will participate in mentoring, tutoring, and individual career counseling and exploration. On Thursdays, they will be engaged in workshops, tutoring, and Intensive University Seminars. On both days, the Provost Scholars will tentatively be on CWRU campus from 2:30 p.m. to 5:00 p.m. It is possible there may need to be a deviation from this schedule or a move to virtual programming for any number of reasons. We will keep you informed if a schedule change is ever necessary.

Failure to attend programming or lack of attendance (in-person or virtual) without prior clearance with the Provost Scholars Team are cause for removal from the Provost Scholars Program per our Code of Conduct.

I grant my scholar permission to participate in the ProvostScholars Program for the 2025-2026 academic year. I also give my scholar permission to travel with the Provost Scholars on local and regional field trips and to other educational activities that are supported by the program.

Name of Provost Scholar *

Signature of Parent/Guardian *

Additional instructions for the previous question. By e-signing this form, I attest that I am the legal parent/guardian of the Scholar and I am authorized to make decisions and grant permissions on behalf of the Scholar.

Date *

Introduction: Letter of Agreement

Dear Provost Scholar Parent/Guardian,

Thank you for taking the time to read the Provost Scholars Program Letter of Agreement! After reading the agreement, please be sure to initial by the appropriate statements and sign and date at the end. We will provide a copy of this agreement for your records. The program expectations are as follows:

Program Participation and Attendance

The Provost Scholar is expected to attend and fully participate in each program session, which is held every Tuesday and Thursday from 2:30–5:00 p.m.
The parent/guardian and Scholar are encouraged to communicate with the Provost Scholars Program team members, via email or phone, at least 24 hours in advance of the event if the Scholar will not be attending a session.
If a Provost Scholar misses a session without communicating with the program team members, for any reason, someone from the program will contact the parent/guardian to discuss consequences and a contingency plan.
During the seminars and weekly Mentor/Scholar meetings, the Provost Scholar will be expected to refrain from distractions or using electronics not related to programming.
If the family is experiencing connectivity issues during virtual programming, please contact the Provost Scholars team for assistance.

Provost Scholars Academic Learning

The Provost Scholar is encouraged to read and study for all of their academic lessons and fully participate in their classes at school.
In order for the Scholar to be able to fully participate in school and the Provost Scholars Program, as well as derive all of the necessary benefits for academic learning, it is imperative they obtain an adequate night’s rest.
Limiting television, non-essential internet activity, and video games can help to improve the scholar’s learning and attention. We ask the parent/guardian to work with their Scholar to reduce these activities during the week.

Parent/Guardian Engagement and Involvement

The Provost Scholars Program will hold the Parents’ College at Case monthly for the parents and guardians of our Provost Scholars. These college sessions have been scheduled for the second Saturday of every month, unless otherwise noted. The parent/guardian is expected to attend all of the sessions throughout the school year.
The parent/guardian will provide updated contact information including, but not limited to, phone and mailing information.

Parent/Guardian Permission for Program Evaluation

We are continually seeking to improve our program and resources and to facilitate this improvement. Periodically, we will ask you to complete surveys. These surveys will be distributed at the mid-point of the program, and again at the end of May. We will be distributing surveys to your scholar in order to solicit their feedback about the program as well.

Thank you for taking the time to read and complete this agreement. If you have any questions, you may contact the program director, Dr. Faye Gary, at fgary@case.edu or phone 216-368-5240 or the program coordinator, Latonya Shazor, at Lxs854@case.edu or phone 216-512-1747.

Important Information about the next question. Parent/guardian must checkl each box to signify understanding and agreement.

The Parent/Guardian of the Provost Scholar is Asked to Commit to the Following: *

I will ensure that my Provost Scholar attends each session.

I will work with my Provost Scholar to eliminate their cell phone use during program sessions.

I will communicate information about my scholar's absence from the program to the program team members and to the school principal.

I will check regularly with my Provost Scholar to help assure that they have completed all of their homework assignments and are up-to-date on their school projects.

I will work with my scholar to ensure they are reading and studying for at least 20 hours each week outside of the school day.

I will encourage my scholar to pursue their desired profession by helping them to create an academic and career plan.

I will limit the number of hours my scholar consumes television and/or plays video games.

Full Name of Provost Scholar *

Full Name of Parent/Guardian *

Parent/Guardian Signature *

Provost Scholars Code of Conduct

The Provost Scholars Code of Conduct

The purpose of the Code of Conduct for Provost Scholars is to clarify expectations for the scholars, their parents, mentors, tutors, school personnel, program visitors, and the general public. This document details the minimum standards and particular importance of acceptable behaviors while participating in the program. It will also provide a common understanding about the high expectations of the Provost Scholars, the program requirements, and our emphasis on safety.

EXPECTATIONS

1. Provost Scholars are to be in attendance and on time to all programming activities.

If a Provost Scholar is going to be late or absent from programming, the program coordinator and program director must be notified 24 hours before the absence. In the case of emergencies, the notification must be as early as possible.
This notification of absence or tardiness must be in writing. An email or text from a known parent/guardian is acceptable. The principals can also inform a member of the Provost Scholars team about the absence or tardiness or emergency.
Scholars may not excuse themselves from activities. They must have parent/guardian or validation from the school principal.
Scholars may participate in other after-school activities that conflict with programming if prior arrangements have been made with the program director.

2. Scholars must dress appropriately. Please refer to your school's dress code for guidance.

3. Visitors to the Provost Scholars activities must be approved by the program director.

4. Disruptive and disrespectful behavior during programming will not be tolerated, including but not limited to:

Inappropriate language;
Physical violence, threat of violence, or inappropriate physical contact;
Participating in trolling, or making insulting, demeaning, or derogatory comments about another person or their family or life situations in person, in text messages, or online;
Using sexual-based language or imagery or engaging in sexual advances with words or behaviors in person, through text messages, or through the Internet; Displaying attitudes and behaviors that require interventions by team members;
Unauthorized cell phone use;
Speaking when others have the floor;
Behaving in a disruptive manner;
Causing injury or harm to self, others, or property;
Not picking up after oneself;
Refusing to participate in programming activities.

5. The parents/guardians of the Provost Scholars must notify the program coordinator, the program director, or the associate director of any changes to transportation arrangements in writing before the event in question. Without written permission on file, all Provost Scholars will be transported to and from Case Western Reserve University on the school bus.

Parents/guardians must plan to be prompt in dropping off or picking up their Provost Scholars from events.
A Provost Scholar will not be released to any other person not listed in the Provost Scholar’s permission files unless express written authorization has been granted before the event by the parent/guardian. Verbal statements or last-minute phone calls will not be considered as approved for an alternative form of transportation.

CONSEQUENCES

First offense: Verbal warning to the Provost Scholar and written warning to be filed in their portfolio by Provost Scholars Team Members. Parent/guardian and school administration may also be notified.
Second offense: Written warning and contact with parent/guardian and school administration.
Third offense: Removal from Provost Scholars Program may be recommended, and letters to parents/guardians and school administrators will complete the process.

Parent/Guardian Signature *

Provost Scholar Signature *

Date *

Parent/Guardian Contact & Emergency Contact Information

Full Name of Provost Scholar *

Name of Parent/Guardian *

Relationship to Scholar *

Parent/Guardian Address *

Additional instructions for the previous question. Please include street number, street name, any apartment numbers, city, state, and zip code

Parent/Guardian Email (will be used to send relevant programming messages--will not be shared with others) *

Parent/Guardian Phone Number *

Is this number a cell/mobile phone? *

Yes

May we text or send messages via Remind to this phone? *

Yes

Additional instructions for the previous question. Please use the box above to indicate any concerns you have about phone/text contact

Comments:

Name of Second Parent/Guardian

Relationship of second parent/guardian to Scholar

Second Parent/Guardian Phone (ONLY include if second parent/guardian is an authorized contact please)

Do you engage in any particular social media? If you would like us to include or tag you in our social media posts, you are welcome to include handles and platforms you use here.

Emergency Contact #1: Full Name of someone who is able to contact the parent/guardian immediately *

Emergency Contact #1: Relationship to Scholar *

Emergency Contact #1: Phone Number *

Emergency Contact #2: Full Name of someone who is able to contact the parent/guardian immediately

Emergency Contact #2: Relationship to Scholar

Emergency Contact #2: Phone Number

Media Release and Clearance for Parent/Guardian/Provost Scholar

I, [insert your name in the box below], enter into this Release with the Case Western Reserve University (CWRU) Provost Scholars Program.
I authorize the Provost Scholars Program to create recordings, photographs, and films of my or my scholar's image, likeness, and voice. These activities are in connection with participation in the program including, but not limited to, mentoring, tutoring, Intensive University Seminars, the Parents' College at Case, and a variety of field trips. I agree that the recordings may take the form of photographs, films, videos, audio tapes, digital files, and any other types of media. The Provost Scholars Program may use the recordings in their original or edited form for its newsletters, websites, social media, and other commercial and educational content to inform educators, parents/guardians, scholars, mentors, and stakeholders about the program in local, national, and global communities.
I also understand that use of the recordings may include, but not necessarily be limited to, the following:
Promoting the partnership between CWRU and your school,
Disseminating information through the administrative offices of your school,
Evaluating program variables for internal and external use,
Streaming in digital format (live) on the Provost Scholars Program website,
Ensuring that the Provost Scholars and other program participants reach their professional and
personal goals as articulated through this program.
I further acknowledge that I will not be compensated for any uses made of the Recordings and that the CWRUProvostScholarsProgramexclusivelyownsallrightstotheseRecordings.However, except for the permissions I am granting here, I retain all rights I may otherwise hold in copyrighted materials that are incorporated into the Recordings.
I hereby waive all rights and release the CWRU Provost Scholars Program (including its officials, employees, representatives, agents, licensees, successors, and assigns) from, and shall neither sue nor bring any proceeding against any such parties for any claim or cause of action, whether now known or unknown, for defamation, invasion of right to privacy, publicity, personality, or any similar matter, or based upon or relating to the use and exploitation of the Recordings.

Parent/Guardian Name *

Parent/Guardian Signature *

Additional instructions for the previous question. I agree that I have read and understood the contents thereof and that I have the right and authority to execute this Release.

Provost Scholar Signature *

Additional instructions for the previous question. I agree that I have read and understood the contents thereof and that I have the right and authority to execute this Release.

Date *

Provost Scholar Data Form

Information from this form will be used to help us better meet your needs as a Provost Scholar. We appreciate you including information in non-mandatory fields to this end. Thanks!

Provost Scholar Name *

Provost Scholar Birth Date *

Address where Provost Scholar currently resides (the majority of the time) *

Additional instructions for the previous question. Please include street number, street name, any apartment numbers, city, state, and zip code

Provost Scholar Phone Number *

Is the number above the Scholar's personal cell number? *

Yes

Additional instructions for the previous question. If the answer is "no" please indicate whose number it is (i.e. parent/guardian/etc.) and their full name in the text box

Comments:

Scholar Personal Email Address (NOT your school email) *

Scholar SCHOOL Email Address *

Name of School *

Grade Level (2025-2026 Academic Year) *

Activities you participate in at school

Activities you participate in outside of school

Additional instructions for the previous question. Please include volunteer work and names of organizations

Special Skills, Hobbies and Interests you have

Additional instructions for the previous question. Examples include reading, solving mathematics problems, playing ball, playing a musical instrument, writing short stories, fixing gadgets, singing, dancing, etc.

Special achievements or awards/recognitions

Adult (unisex) polo shirt size *

XXL

Other

Comments:

Are you currently enrolled in the TRiO Talent Search or Upward Bound program? *

Yes

No (if no, please sign up as a condition of participation in the Provost Scholars Program)

Unsure (please comment below)

Additional instructions for the previous question. If you have not yet enrolled in TRiO, please fill out the application here as soon as possible: https://botform.compansol.com/202245394238051

Comments:

What are your plans for after high school graduation?
What are your current long-term career goals?

Important Information about the next question. Check as many as you wish

Please select the areas where you would like to focus on improving:

Mathematics

English/Writing

Science

Social Studies

Exercise/Physical activity

Personal Health and Wellness

Emotional Intelligence (i.e. social interactions with others)

Career Planning

Procrastination/Time Management

Study/Test-taking strategies

Organization

Emotional Well-being

Virtual Learning Strategies

Other? (indicate in box below)

Comments:

Waiver for All Field Trips and Other Academic Activities Participation Form

Dear Parent/Guardian:

Your son/daughter [Named Below] is eligible to participate in the Provost Scholars Program sponsored activities requiringbus transportation away from the Case Western Reserve University (CWRU) campus and your school. All sponsored field trips and other activities will take place under the guidance and supervision of employees and team members of the Provost Scholars Program, who arealso CWRU faculty and personnel. Faculty from your school may also be involved in these academic-focused field trips and activities.

You and your scholar, as well as the administrators at your school, will be informed about all upcoming academic-focused field trips and activities.

If you would like your child to participate in these events, please complete & sign the following statement of consent and waiverof liability and the emergency contact information.

Consent and Waiver *

I hereby request the participation of my scholar, [Named Below] in the events described above. I understand that these events will take place away from the CWRU and our school grounds, and that my scholar will be under the supervision of the designated Provost Scholars Program team members and, at times, the faculty from our school and other personnel may also be present. I further consent to the conditions stated above, including the method of transportation. Further, if my scholar misses the school bus from their school location, he/she is neither permitted to join the Provost Scholars at the field trip site nor contact a program team member to transport him/her to the field trip destination.

I hereby agree, on behalf of the named Provost Scholar and his/her other parent/guardian, to waive any claims of liability against the Provost Scholars Program, CWRU, our school, and any Provost Scholars Program team members, faculty mentors, volunteers, agents, or employees which may arise from the participation of the named Provost Scholar in the above-described events.

Name of Provost Scholar *

Signature of Parent/Guardian *

Date *