Appendix A

Please sign and return the following page to your child's Senior English Academic Partner.

Parent/Guardian/Student Permission and Liability Form

I have read the Letter to Students and Families relating to the Pride Project and understand that the satisfactory
completion of the research paper, 10 project hours, product, and presentation are required to graduate and
receive a diploma from Pine Lake Preparatory. I also understand that the student and his / her parents are
responsible for any damage or injury to the student or others during the student’s self-selected Pride Project
hours.

Kim Ngo
Parent/Guardian Name(s) (please print)_______________________________________________________

704-941-4151
Parent/Guardian Home Phone(s):____________________________________________________________

704-997-2886
Work Phone(s): ____________________________ (Mother) ______________________________ (Father)

taylorskim@bellsouth.net
Parent/Guardian Email(s): ____________________________________________________________

sonngo@bellsouth.net
____________________________________________________________

09/17/18
Parent/Guardian Signature ​ ___________________________________________ Date ____________

(2​ND​ Signature Optional) ___________________________________________ Date ____________

Student Signature 09/17/18

___________________________________________ Date ____________
Appendix C

Mentor Consent Form

The role of the Mentor is to serve as an expert in the field chosen by the student. By signing this form, the
mentor agrees to: allocate time (a minimum of ten hours) to work with the student; provide insight into the
training, expectations, and demands of the field; ensure that the student is actively involved during shadowing
and not simply observing. If desired, the mentor may provide suggestions, advice, and support regarding the
development of a tangible product that connects to the real-world requirements of the career.

Skyler Ngo
Student Name​ __________________________________________________________________
Orthopedic Surgery
Project Topic ___________________________________________________________________

David C. Hillsgrove, MD
Mentor Name​ ___________________________________________________________________

OrthoCarolina
Place of Employment _____________________________________________________________
124 Welton Way, Mooresville, NC 28117
Work Address ____________________________________________________________________

d.hillsgroveMD@orthocarolina.org
Preferred Email __________________________________________________________________

704-658-1050
Preferred Phone _________________________

Orthopedic Physician
Occupation / Title / Expertise Related to Topic ___________________________________________
________________________________________________________________________________
12 years
Years of experience in topic area ____________________

For the protection of myself and the student, I agree that we will not meet alone. I agree to uphold the
roles/duties of the project mentor to the best of my ability. I also confirm that I am not related to the student.

09/19/18
Mentor Signature​ ________________________________________________ Date ______________

09/17/18
Parent Signature​ _________________________________________________ Date ______________
09/17/18
Student Signature​ ________________________________________________ Date ______________