Parent/Caregiver Interviews Consent

Attachment_7_Youth Survey Parent Permission and Opt-Out Forms_OMB-0930-0373_12.4.19.docx

“Talk. They Hear You.” Campaign Evaluation: Case Studies

Parent/Caregiver Interviews Consent

OMB: 0930-0373

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Attachment 7: Youth Survey Parent/Caregiver Permission and Opt-Out Forms


Parent/Caregiver 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 _______________.




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


Child’s name: _________________________




_________________________ _________________________

Parent/Caregiver Name (Printed) Signature and Date



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


Parent/Caregiver 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 _______________.




_____ I am choosing to opt out my child from participation in the underage drinking prevention

survey.


Child’s name: _________________________




_________________________ _________________________

Parent/Caregiver Name (Printed) Signature and Date



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


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleSchool field trip permission slip
File Modified0000-00-00
File Created2021-01-15

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