YOUTH PERMISSION FORM

![](media/image1.png){width="0.6979166666666666in"
height="0.6479166666666667in"} Parent or Legal Guardian Consent Needed
![](media/image2.wmf){width="0.6458333333333334in" height="0.6125in"}

*FAX OR MAIL COMPLETED FORM TO:*

Agency:

Contact Person:

Street address

City, State, Zip

Phone:

FAX:

We, the undersigned parents (or lawful guardians) of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,
a student at
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_School
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, in the city of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,
in the state of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
do hereby permit our child to participate in the youth involvement
process and program, sponsored by this agency:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

*(If the collaborative partner is not a school or school district and is
some other organization or agency, such as a civic organization,
council, faith community, group, etc., state the name of that entity
here:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)*

We understand this opportunity is voluntary and designed to promote and
improve leadership skills and to produce measurable outcomes in reducing
and preventing the underage use of alcohol and tobacco and use of
illicit drugs.

We acknowledge that youth are expected to obey their instructors,
advisors and designated adult or community coalition chaperones when
engaging in the above mentioned program, processes and events and that
all regular school rules for the child's school district, (or rules of
the hosting civic organization, faith community etc., which serves as
the hosting institution,) are in effect during this educational
experience. We give permission and release our child to appear in
person, in video footage, photos, print, broadcast and electronic media
in regard to the above-mentioned leadership initiative and to
participate in interviews and anonymous surveys, which will be used only
for educational and evaluative purposes. We understand that there is no
financial remuneration involved for the appearance(s) of the leadership
candidates or graduates.

We, the undersigned, likewise shall indemnify, protect, and hold
harmless (names of hosting agencies), our child's teacher and School
District, (or advisors of the above partnering civic organization,
agency, faith community, council or group,) and those agencies or
organizations hosting or collaborating in the above mentioned leadership
initiative, their servants, agents or employees, from any liability
imposed as a result of accident, injury or death to the aforesaid youth
which is incurred while said youth is participating in this activity. We
understand, however, that this waiver and indemnification shall not
apply to independent acts of negligence on the part of the aforesaid
sponsors.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Parent or Lawful Guardian Signature and Date Youth Signature

*Print the names on the lines below, of the persons signing on the lines
above.*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Home Street
Address:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
City, State, Zip\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Youth Email: MANDATORY
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Home Phone: ( ) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Parent Work
Phone: ( )\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Please complete your LEADERSHIP CANDIDATE INFORMATION**

**Date:**

**First Name:**

**Middle Name:**

**Last Name:**

**Street Address:**

**City, State, Zip Code:**

**Phone Number:**

**Age:**

**Birth Date/Year:**

**Name of Parent/Lawful Guardian:**

**Address of Parent/Lawful Guardian:**

**Home Phone Number of Parent/Lawful Guardian:**

**School:**

**Present Grade:**

**Advisor Name and Agency, School or Organization:**

**Phone Number for Advisor:**

**Adult Recommending You:**

**Home Email address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Please Print Clearly Below**

**Hobbies, Talents, Interests:**

**Why do you want to become a better leader to fight underage drinking,
teen tobacco use, second hand smoke and illicit drugs?**

**Adult References**

**Provide Contact Information for Three Adult References *(not family)*
to Verify Leadership Qualities**

*(Examples: teacher, coach, pastor, neighbor, family friend, neighbor,
dance instructor, Scout leader)*

**1.**

**Name:**

**Street Address:**

**City, State and Zip Code:**

**Phone:**

**Email:**

**How does this person know you? Why would they say that you have
leadership qualities?**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**2.**

**Name:**

**Street Address:**

**City, State and Zip Code:**

**Phone:**

**Email:**

**How does this person know you? Why would they say that you have
leadership qualities?**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**3.**

**Name:**

**Street Address:**

**City, State and Zip Code:**

**Phone:**

**Email:**

**How does this person know you? Why would they say that you have
leadership qualities?**

**Pass the Torch!**

List three possible peer contacts that you believe you could tap to
enroll in this activity.

**1. Name:**

**Street Address:**

**City, State and Zip Code:**

**School, Grade and Age:**

**Phone:**

**Email:**

**2. Name:**

**Street Address:**

**City, State and Zip Code:**

**School, Grade and Age:**

**Phone:**

**Email:**

**3. Name:**

**Street Address:**

**City, State and Zip Code:**

**School and Grade:**

**Phone:**

**Email:**