MESA Buddies-Elementary Student Authorization

Your son/daughter has been invited to participate in New Mexico Mathematics, Engineering, Science Achievement, Inc. NM MESA, Inc., is an educational program designed to encourage and prepare students for college majors and careers in mathematics, engineering, science and related fields. NM MESA, Inc. assists these students by offering the following and more:

Rigorous Academic Schedule • Weekly Tutoring • Field Trips • Competitions • Academic & University/Career Counseling • Leadership Workshops

Participating students receive the educational enrichment experiences and practical help they need to achieve academic excellence and prepare for college. NM MESA, Inc. is a very successful program - 78% of MESA graduates go on to college or a university and 49% have chosen majors in math, engineering or science.

As an elementary student, your student in not eligible for some NM MESA programming, but will participate in our MESA Buddies program.

I am pleased to have my child participate in NM MESA, Inc. By completing, this form I agree to the minimum requirements for participation in the MESA program. I give permission to NM MESA, Inc., and its funding agencies, to use my child's name and photograph in press releases, newsletters, reports, video, website, social media and any other documentation used by NM MESA, Inc. as needed in promotion and reporting for the MESA Buddies program. I give permission for my student to participate in instruction virtually or in person with NM MESA Staff, Teacher Advisors, and/or MESA students.

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* 1. Student Contact Information

Name

Elementary School

Mailing Address

City/Town

State/Province

ZIP/Postal Code

Parent/Guardian Email Address

Parent/Guardian Phone Number

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* 2. Student Grade

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* 3. Student Ethnicity

Hispanic (Spanish culture of origin)

Anglo (not Hispanic origin)

Black (not Hispanic origin)

Asian or Pacific Islander

American Indian/Alaskan Origin

Undeclared/Other (please specify)

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* 4. Student Gender

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* 5. Does student have a disability?

Yes

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* 6. Does student participate in a free/reduced lunch program?

Yes

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* 7. I have read, understand and agree to the minimum requirements for participation in the MESA program. Information collected will be used for reporting purposes only. There is no entry requirement to participate in a NM MESA program. If yes, provide parent/guardian name.

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* 8. Submitted:

Date / Time

Date

Time

AM/PM