Dear Parent,
Your son or daughter has the chance to take part in an exciting and fun program to help young people
learn about their health. The purpose of the program is to help young people:
 Explore goals for their future
 Practice decision-making skills
 Learn how to prevent sexually transmitted disease and pregnancy
About the Program
During insert program name here, your child will take part in small group discussions, videos, and games
that teach about health problems—teen pregnancy and STD, such as HIV/AIDS—and how they can be
avoided. The program has lessons on waiting to have sex until a teen is older. Your child will learn
important lessons in a caring and fun way.
The program will take place at insert location here, on insert days and times here.
You are welcome to review the program and the teaching materials before the program starts. If you
would like to see the materials or talk to someone about the program, please contact insert program
contact information here.
About the Survey
This program is funded by the Gaston Youth Connected project, through a grant from the CDC. As part
of the program, your child will be asked to take a survey at the start and end of the program. The survey
asks:
 Race, age, and school
 How they think they will behave in the future
 If they liked the program
 What they learned in the program, such as:
o not having sex as the best way to stay healthy
o types of birth control and how to use it so it works
o where teens can get birth control if needed
For students who have had sex, the survey asks what they do to prevent pregnancy and disease.
Your child does not put his/her name on the survey. An ID number is used. We do not share answers
for individual surveys. We look at answers for the group as a whole and not for individual students.
Your child does not have to answer any question they do not want to. If they do not answer a question
or take the survey, they can still take part in the program.
If you have questions about the survey, contact insert program contact information here, or Joy
Sotolongo 919-226-1880x102. Leave a message with the best time to reach you.
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Version 2: September 2013
PERMISSION TO TAKE PART IN THE PROGRAM
I have read and understand the information given above. I understand that I can ask questions and
review program material. I agree to have my son/daughter take part in the program.
Child’s First and Last Name: ______________________
________________________
Child’s Date of Birth: ________________________ (mm/dd/yyyy)
Parent/Guardian’s name: _______________________ Parent/Guardian Phone number: ____________
Parent/Guardian signature: ________________________________________________________
PERMISSION TO COMPLETE PROGRAM SURVEY
I have read and understand the survey information given above. I understand that no names are used on
the survey and that my child can take part in the program if I do not give permission for the survey. I can
ask questions about the survey.
 Yes, my son or daughter may complete the survey.
 No, my son or daughter may not complete the survey.
Parent/Guardian signature: ________________________________________________________
INFORMATION ON HEALTH CARE - OPTIONAL
Gaston Youth Connected aims to reduce teen pregnancy. The project also works with doctors to help
them be teen-friendly, including how to talk with teens about sexual health. If you feel comfortable
sharing where your son or daughter receives health care, please select ALL the doctors your child sees.
If your child’s doctor is not on the list, please feel free to add it. We want to help all doctors deliver
teen-friendly services.
We will keep this information private. We will not share the name of your child or their doctor.
We will use this information to see how many youth in our programs also see a doctor who is involved in
the project – and to see if other doctors are interested in learning more about teen-friendly health
services.
Gaston County Health Dept.
Gaston Family Health Services
Ashley Women’s Center
Courtview GYN
Gaston Pediatrics
Other:
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Revised 10/1/13
Photo Release Form
If you are under 18, please have your parent or guardian sign this form.
If you are 18 years old or older and/or live independent from your parents, then
you can sign on your behalf.
I,____________________________________________, understand and agree that all pictures
and video of me, my child, and/or my property shot by Gaston Youth Connected staff or their
designees may be shared with and used by Adolescent Pregnancy Prevention Campaign of
North Carolina (APPCNC) as part of the Gaston Youth Connected project. I authorize the use of
this material and my/my child’s name, likeness, and photograph for the purpose of producing,
advertising, and promoting the project.
I agree that APPCNC owns the production in which said material is used and owns all results and
proceeds of the use of my/ my child’s name, likeness, and photograph. I also agree that APPCNC
has unlimited rights to record, license, distribute, broadcast, and exhibit this material or portions
of this material and its results and proceeds or to cause others to do the same by means of any
type of technology, either known or not yet known, in all territories without compensation to me.
With respect to the use of the materials described above, I do not hold APPCNC liable for any
legal action that may result from my/my child’s appearance in any APPCNC production or
publication.
In signing for a minor, I confirm that I am either over 18 or am the child’s parent or legal guardian.
I understand and agree that all the provisions of this document apply to me/the minor named
below.
____________________________ _____________ _____________
___________________
Signature of Parent/Guardian or Youth Older
than 18
Date
__________________________________________________________
Printed Name of Parent/Guardian or Youth Older than 18
Revised 10/1/13