Provost Scholars Permission Forms 2026-2027

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 2026-2027 Academic Year. The mission of the Provost Scholars Program is to improve the academic outcomes of our scholars and prepare them for college. Through mentoring, tutoring, networking, and relationship building with the CWRU community, 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, tutoring, university seminars, and other activities. Your student will also be matched with a faculty member at CWRU. Twice weekly, your student 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 have the opportunity to meet your Scholar’s mentor and program staff during the year.

In service of your student's growth and development, we are requesting that you give permission to program team members to communicate with your student's school to discuss grades and access relevant data. Before mentors can communicate and interact with Scholars they will complete an orientation and training program, conducted by the Provost Scholars team members, and undergo background checks.

Furthermore, we are requesting that you participate in the Parents’ College at Case, which convenes on the second Saturday of every month, (October 2026-April 2027), from 10:30 am to 12:00 pm. The purpose of the Parents’ College at Case is to support and educate families so they can support their Scholars. Parent/Family Orientation will be held on Saturday, October 3, from 10:30 am - 12:00 pm at Guilford House and will include detailed information about the program and its requirements. If you agree that your student has your permission to participate in the Provost Scholars Program, please read, sign, and return the following forms.

Sincerely,

The Provost Scholars Program Team

The Provost Scholars are in the Relentless Pursuit of Excellence.

Parent/Guardian Permission Form

My child has my permission to participate in the Provost Scholars Program at CWRU which will necessitate that they interact with a mentor once a week, participate in tutoring sessions, field trips, seminars and other activities that occur on the CWRU campus and other designated sites. I understand that the program may 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. On Thursdays, they will be engaged in 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. If necessary, this schedule could change. We will notify you of any changes that occur.

Failure to attend programming or lack of attendance without prior clearance with the program staff is cause for removal from the Provost Scholars Program per our Code of Conduct.

I grant my scholar permission to participate in the Provost Scholars Program for the 2026-2027 academic year. I also give my scholar permission to travel with the Provost Scholars on field trips (both local and regional) 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. The program expectations are as follows:

Program Participation and Attendance

Each Provost Scholar is expected to attend and fully participate in all program sessions 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 an event if the Scholar will not be attending.
If a Provost Scholar misses a session without communicating with the program staff, someone from the program will contact the parent/guardian to discuss expectations and clarify an attendance plan.
Each Provost Scholar will be expected put their cell phone away during programming as per our Cell Phone Use Policy.

Parent/Guardian Engagement and Involvement

The Provost Scholars Program will hold Parents’ College at Case monthly for families/guardians of Provost Scholars. These sessions have been scheduled for the second Saturday of every month, unless otherwise noted. Parent Orientation will be held Saturday, October 3, 2026 from 10:30 am - 12:00 pm on the CWRU campus. Families/guardians are expected to attend.
Parents/guardians are expected to update the program staff of any changes to their contact 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 Kate Burleigh, at kbb56@case.edu or by phone at 216-368-6180.

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 ensure my Provost Scholar follows the Cell Phone Use Policy during programming.

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

I will work to limit the time my scholar consumes media or plays video games.

I will encourage my Provost Scholar to read, daily.

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 also provides a shared understanding about the expectations for 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.
Notification of absence or tardiness must be in writing. An email or text from a known parent/guardian is an acceptable form of notification. School principals can also inform a member of the Provost Scholars team about an absence or tardiness emergency.
Scholars may not excuse themselves from activities. They must have parent/guardian or validation from their 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 by a parent/guardian. Without written permission, 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 are not considered acceptable means of changing arrangements.

CONSEQUENCES FOR CODE OF CONDUCT VIOLATIONS

First occurrence: Verbal warning to the Scholar and written warning placed in their portfolio by Provost Scholars Team Members. Parent/guardian and school administration may also be notified.
Second occurence: Written notification and contact with a parent/guardian. School administration will be notified.
Third occurrence: Depending on the nature of the occurrence, removal from the Provost Scholars Program is possible. Program leadership will meet with the Scholars, their family and the school.

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 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)

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 child [Named Below] is eligible to participate in the Provost Scholars Program sponsored activities requiring bus 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 are also 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 *