Peer Power Permission Form
Permission Slip
Positive Peer Pressure Support Group
Return By
Student Information
Student Name
Grade
4th Grade
Teacher Name
Date
Small Group Details
Group Description
The Fourth Grade Positive Peer Pressure Support Group helps students recognize and encourage positive behaviors among classmates while building strategies to resist negative influences and lead with confidence.
Goals
- Identify leadership and positive influence
- Practice kind, encouraging language
- Develop "saying no" strategies
Schedule
Location:
Teacher Contact
Phone
Email
Parental Consent
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 this support group.
Parent/Guardian Name
Signature
Date Signed
Please return this signed form to your child’s classroom teacher by the date indicated in the top header.
Permission Form Script
Permission Form Script
Facilitation Guide • 30 Minute Meeting
Teacher Resource
Objective
Use this script to introduce the Positive Peer Pressure Support Group to parents. The goal is to ensure they understand the "Tier 2" intervention, feel comfortable with the objectives, and provide signed consent.
1. Welcome and Purpose
5 Minutes
"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."
"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."
Prompt Questions:
"Does anyone have a question about why we’re focusing on positive peer pressure?"
"What are some ways you’ve seen kids encourage each other in class or on the playground?"
2. Explain Group Details and Goals
10 Minutes
"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. Under Goals/Objectives, our targets are:
- Recognize situations where peers influence each other positively or negatively.
- Use supportive phrases and actions to uplift classmates.
- Practice firm, respectful responses to say ‘no’ to unhelpful pressure.
I’ll guide each student through real-life scenarios, role-plays, and group discussions. We’ll keep track of progress and celebrate each success!”
Page 2
3. Walk Through the Form
10 Minutes
"Let’s review each section. Please follow along and ask questions at any time:"
1. Student Info "I've filled in my name and grade. Please add your child's name."
2. Schedule "Planned for April 5th, 12th, and 19th (3:15-3:45 PM)."
3. Location "We'll meet in Room 12."
4. Contact Info "Reach out anytime via phone or email."
5. Permission "Please check 'I give permission' or 'I do not give permission'."
6. Signature "Sign, date, and return by this Friday, March 29th."
4. Q&A and Signing
5 Minutes
"Now I’ll hand out the forms. Please complete the blanks, select your permission choice, and sign at the bottom... Thank you for your support! I’m looking forward to guiding our students toward positive leadership."
End of Script
Permission Slip Warm Up Activity
Warm-Up Activity
Positive Peer Influence & Support
5 Minutes
Parent Meeting
Today's Focus
Before we review the group details, let's think about the power of positive peer influence. How can students uplifting one another change their school experience?
1
Individual Reflection
2 Minutes
Write two benefits you’ve seen or hope to see when children support each other and encourage positive choices.
Benefit One
Benefit Two
2
Turn-and-Talk
2 Minutes
- Share your two benefits with the person sitting next to you.
- Together, choose one benefit you both agree is most important.
Our Top Shared Benefit
3
Whole-Group Share
1 Minute
We’ll go around quickly—each pair names their chosen benefit in one sentence to get our collaborative energy flowing!
These ideas will guide our review of the Small Group Permission Form and help us support students in building strong, positive peer relationships.
