Small Group Permission Slip

Please complete this form and return it by ____________. Thank you for your prompt response!

Student Information

Student Name: _________________________________



Grade: 4th Grade



Teacher Name: _________________________________



Date: ________________________________________

Small Group Details

Group Title/Description:

Fourth Grade Positive Peer Pressure Support Group

In this group, students will learn how to recognize and encourage positive behaviors among classmates, and build strategies to resist negative influences.

Goals/Objectives:

• Identify examples of positive peer influence and leadership.

• Practice using positive language and encouragement with peers.

• Develop confidence and strategies to say “no” to negative peer pressure.

Session Schedule (Date & Time):

1. ____________________________________________
   
2. ____________________________________________
   
3. ____________________________________________
   
   

Location:

______________________________________________

Contact Information

Teacher Contact:

Phone: _______________________________________

Email: _______________________________________

Permission

Please check one:


[ ] I give permission for my child to participate in the Positive Peer Pressure Support Group sessions described above.


[ ] I do not give permission for my child to participate in the Positive Peer Pressure Support Group sessions described above.

Parent/Guardian Name: _________________________



Signature: _____________________________________



Date: _________________________________________

Return Instructions

• Please return this signed form to your child’s classroom teacher by ____________.

• If you have any questions, feel free to contact me at the phone number or email above.

Permission Form Script

Use this word-for-word script during your 30-minute parent meeting to introduce, explain, and collect the Small Group Permission Form for our Positive Peer Pressure Support Group. Adjust timing as needed.

1. Welcome and Purpose (5 minutes)

Teacher: “Good evening, everyone! Thank you for joining me tonight. I’m Ms. Lopez, your child’s fourth-grade teacher. I’m excited to tell you about a new Tier 2 small group we’re starting called the Positive Peer Pressure Support Group.

Teacher: “In this group, students will learn how to spot and celebrate positive behaviors, support one another kindly, and practice strategies for saying ‘no’ when faced with negative peer pressure. Your child was selected because I know they have great potential to lead and grow in these skills.

Teacher: “Before we dive in, does anyone have a question about why we’re focusing on positive peer pressure?

Possible follow-up if needed:

• “What are some ways you’ve seen kids encourage each other in class or on the playground?”
  
  

Teacher: “Wonderful—let’s look at how this group will work and get your permission.”

2. Explain Group Details and Goals (10 minutes)

Teacher: “On the permission form, you’ll see Group Title/Description. I’ve written ‘Fourth Grade Positive Peer Pressure Support Group.’ We’ll meet for three 30-minute sessions. During these meetings, your child will:

• Identify examples of positive peer influence and leadership.

• Practice using kind, encouraging language with classmates.

• Build confidence and learn strategies to resist negative peer pressure.

Teacher: “Under Goals/Objectives, our targets are:

1. Recognize situations where peers influence each other positively or negatively.
   
2. Use supportive phrases and actions to uplift classmates.
   
3. Practice firm, respectful responses to say ‘no’ to unhelpful pressure.
   
   

Teacher: “I’ll guide each student through real-life scenarios, role-plays, and group discussions. We’ll keep track of progress and celebrate each success!”

3. Walk Through the Form (10 minutes)

Teacher: “Let’s review each section. Please follow along and ask questions at any time:

1. Student Information – I’ve filled in my name and your child’s grade. Please add your child’s name and today’s date.
   
   
2. Session Schedule – You’ll find three blank lines labeled Date & Time. I’ve tentatively planned sessions for April 5th, April 12th, and April 19th, right after school from 3:15 to 3:45 p.m. If these times don’t work, let’s pick better slots afterward.
   
   
3. Location – We’ll meet in Room 12, our classroom.
   
   
4. Contact Information – My phone number and email are listed here. Feel free to reach out with questions or changes.
   
   
5. Permission Checkbox – Please check “I give permission” or “I do not give permission” for your child to join the Positive Peer Pressure Support Group.
   
   
6. Signature and Return – Sign and date at the bottom, then return the form by this Friday, March 29th. You can write that date on the blank, if it helps you remember!
   
   

Teacher: “Questions about any of these parts?”

Possible prompts:

• “Why is it important to sign and date today’s form?”
• “Who might need to choose a different day because of after-school activities?”

4. Q&A and Signing (5 minutes)

Teacher: “Now I’ll hand out the forms. Please complete the blanks, select your permission choice, and sign at the bottom. If you prefer your child not join, just check the ‘do not give permission’ box. I’m here to help if you have any questions.

Teacher: “Thank you for your support! I’m looking forward to guiding our students toward positive leadership and healthier choices. Please turn in your form before you leave, and feel free to chat with me afterward.”

End of Script

Permission Slip Warm-Up

Purpose: Activate thinking about the power of positive peer influence before reviewing our permission form.

Time: 5 minutes

1. Quick Individual Reflection (2 minutes)

On the lines below, write two benefits you’ve seen or hope to see when children support each other and encourage positive choices.

1. _________________________________________________________________
   
   
   
2. _________________________________________________________________
   
   
   

2. Turn-and-Talk Pair-Share (2 minutes)

• Turn to the person next to you and share your two benefits of positive peer influence.
• Together, choose one benefit you both agree is most important.

Our top benefit: ___________________________________________________

3. Whole-Group Share (1 minute)

We’ll go around quickly—each pair names their chosen benefit in one sentence.

These ideas will guide our Small Group Permission Form discussion and help us support students in building strong, positive peer relationships.