One of Many - Churchill Community Coalition

One of Many Permission Slip

Dear Parents/Guardians:

The Churchill Community Coalition is studying teen alcohol and substance use and awareness in an effort to better serve our community and provide prevention programs and services. We are talking directly with young people in Churchill County.

Your child has been selected to participate in small group discussions through which we hope to learn about how teenagers think about stress coping and substance use. We want to know what teens think is important for developing strong relationships with their parents and their ideas about the best types of programs to support parents and teens. We will use what we learn from these groups to design future programs for families.

Your child's participation in the focus group is voluntary. She or he does not have to answer any question that feels uncomfortable. The focus group will be recorded on audiotape so that study leaders can pay full attention during the discussion. What your child says during these group is confidential. Their real name will not be included in any reports. The only people who will have access to the notes, recordings or information from the groups are the group leaders.

Your child needs your permission to participate in these discussions. The small group discussions will take about 30-minutes to 1 hour and will take place at the CCMS or CCHS Native Student Education program rooms. There will be about 5-12 young people participating in the group discussions. All youth participants will receive lunch, and other incentives.

Please complete the attached permission slip and have your child return it to the teacher that gave it to them.

If at any time you have questions or concerns about this focus group, please do not hesitate to contact the local group coordinator or group leader.

Local Coordinator/Group Leader Group Leader

Kadie Zeller Lara Vo

90 N. Maine St, Fallon, NV 89406 90 N. Maine St. Fallon, NV 89406

775-423-7433 775-423-7433

Kadie@churchillcoalition.com Lara@churchillcoalition.com

Thank you in advance for your support on this project.

Sincerely,

Kadie Zeller, Project Coordinator

My Child *

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Checkboxes *

May participate in the focus groups
May NOT participate in the focus groups

I understand that my child is responsible for his/her own transportation to return home the day of the focus group. *

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Last

Parent/Guardian Signature *

Date *

Emergency Contact *

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Phone *

I understand that audio recordings, videos and photographs of participants are taken during some events and activities. Some of these pictures may appear in the media, i.e. newspapers, flyers, websites, social media, brochures etc., explaining and promoting Churchill Community Coalition (CCC) programs. I grant the “CCC” and their agents absolute rights and permission to use photographic portraits, pictures, digital images or videotapes of My Child, or in which My Child may be included in whole or part, or reproductions thereof in color or otherwise for any lawful purpose whatsoever, including, but not limited to, use in any “CCC” publication or on the “CCC” websites or social media platforms, without payment or any other consideration. CHECK ONE: *

CONSENT: I hereby certify that I am the parent/guardian of the above named child and DO give my consent to have my child filmed/photographed/recorded
NON-CONSENT: I hereby certify that I am the Parent Guardian of the above named child and DO NOT give my consent to have my child filmed/photographed/recorded.

Parent/Guardian Signature *

Date *

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