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Parental Permission Form



Or, please print out this form, complete it, and fax it to 980-939-7997, mail it to PO Box 604, Statesville, NC 28687 or scan and email to: mediationwithsusan@gmail.com.

Your child __________________________________________ has been referred to Piedmont Mediation Center by ____________________________________________________ (school) in regard to a conflict at school, a behavioral issue, a truancy issue, or to be part of a group of students participating with us. 

Participation is always voluntary.

Piedmont Mediation Center is an approved Partner with the Iredell Statesville School System and the Mooresville Graded School System, and has been working with families and students for 15 years. 

If Juvenile Services or law enforcement is involved, they will decide whether there are additional steps that the parties must complete.  If your child was referred from Juvenile Services, please follow up with their Court Counselor. 

With your permission, we may meet with the students at school or schedule a time to meet after school. 

By signing and returning this letter you are giving permission for your child to participate in this process.  If you have questions or concerns you would like addressed, please contact me at 704-873-7624 or email me.

Thank you for allowing Piedmont Mediation to be of service to you and your family.

Susan Smith
Youth Program Coordinator
mediationwithsusan@gmail.com

I, _____________________________________________, (parent/guardian name) give permission for

_______________________________________________ (youth's name) to participate with Piedmont Mediation.

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