Parent/Caregiver Interviews Consent

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.