MHE and Me
Parental Consent Form
I  give permission to MHE and Me to publish a web page for my child.  I understand that information for the page is to be provided by my child and myself. My child understands that he or she will be sharing his or her story or poetry with other people and is comfortable with that.   It is up to you and your child whether you would like a photo or photos to appear on the page.

I understand that no last names, addresses, or phone numbers will appear on my child's page, and that MHE and Me has the right to  edit my child's story, poem, or other submission as appropriate and/or necessary.

I understand that my child and I will have the opportunity to review the Web page before it is published to the MHE and Me Web Site, and will have an opportunity to request changes, additions, or deletions at that time.   I may request additional changes to my child's page at any time, by emailed request to mheandme@yahoo.com.

(  )  Please post my child's email address on his/her page. That email address is:

       __________________________________________________________________

(  )  Please DO NOT post my child's email address on his/her page. Instead, please post a notice that anyone wishing to contact my child may do so c/o MHE and Me, and that any messages received for my child will then be forwarded by MHE and Me to us.

I understand that I may contact MHE and Me and ask to have my child's email address either deleted from or added to the web page, by emailed request to mheandme@yahoo.com

(   )  I am submitting my child's story/poem for creation of a web page on the MHE and Me Web Site.
(   )  I will be forwarding my child's story/poem separately, by email



Child's Name:____________________________________________


Age: ______________________

Present Grade in School:_______________________

Address:_________________________________________________________________

City:_____________________________State:____________

Zip Code:_____________

Telephone Number: _______________________________________

Parent/Guardian:__________________________________________________________

Email address for parent/guardian:___________________________________________

Favorite colors (for Web page design):________________________________________

(   ) My child would like to have a pen pal(s). 
                       

___________________________________________
Signature of Parent or Guardian


____________________________________________                           
Date

Please mail the completed form to:
Susan Wynn
MHE and Me
PO Box 651
14 Stony Brook Drive
Pine Island, NY 10969