Youth Survey Parent Permission and Opt-Out Forms

Attachment 4: Youth Survey Parent Permission and Opt-Out Forms

Parent Permission Form

If you are allowing your child to participate in the Substance Abuse and Mental Health Services Administration (SAMHSA) survey about underage drinking, please complete the following form by January 25, 2017.

_______ I am choosing to allow my child to participate in the underage drinking survey.

Child’s name: _______________________

__________________________ ___________________________

Parent/Caregiver Name (Printed) Signature & Date

The completed form can be returned to your child’s homeroom teacher or principal.

Parent “Opt-Out” Form

If you do NOT want your child to participate in the Substance Abuse and Mental Health Services Administration (SAMHSA) survey about underage drinking, please complete the following form by January 25, 2017.

_______ I am choosing to “opt-out” my child from participation in the underage drinking survey.

Child’s name: _______________________

__________________________ ___________________________

Parent/Caregiver Name (Printed) Signature & Date

The completed form can be returned to your child’s homeroom teacher or principal.