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Today's Date: April 16, 2025

 

Dear Parent/Guardian,

Your child has been invited to participate in the Voices Program at their school or community program! Through a variety of discussions, activities, and games your child will build new connections with peers and learn important skills for:

  • Communication
  • Expressing Feelings
  • Making Healthy Choices
  • Creating Healthy Friendships
  • Resisting Negative Peer Pressure
  • Setting Goals

This small group of 6 to 8 youth will meet weekly or bi-weekly for up to 12 weeks. The group sessions last for about an hour and are held during the regular school day or as part of an after-school program.

Please give your consent to the statement below and complete this short registration form if you would like your child to participate. If you have any questions, please contact the program director at the number below.

Sincerely,

Volunteers of America, Utah

Prevention Services

(801) 364 – 0744 x722

 

I hereby give my informed consent for my child to participate in the Volunteers of America, Utah Voices Program. I understand that this program is voluntary and that my child is not required to participate. I understand that my child may be pulled from their class during school hours for group sessions. I give permission for my child to meet via Zoom live video conferencing. I give permission for the group mentor to talk with my child’s teacher, school counselor, and/or program director about their progress in the program. I understand that my consent can be withdrawn at any time by notifying the group facilitator by phone and that my consent will expire when the program ends.

I Agree

Please select who will be participating...
Minor
Continue
First Participant's Name

First Name*

Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
Gender*

Please specify a gender identity not listed...
Race/ Ethnicity *
Hispanic / Latino (of any race)
Native American / Indigenous
Black / African American / African
Asian
Native Hawaiian / Pacific Islander
White / Caucasian
Bi-Racial or Multi-Racial
Race/ ethnicity not listed here

Please specify a race/ ethnicity not listed...

Youth's School *
Grade*

Youth's Email (if applicable)

Youth's Phone Number (if applicable)
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Parent or Guardian's Phone Number

Phone Number *
Permission to Participate in Pre / Post Survey
Youth are asked to complete a pre and post survey to evaluate the effectiveness of the program. You must give permission for your child to complete the survey. Your child's participation is voluntary. If your child does not participate they will not be penalized or lose any benefits to which they are otherwise entitled. Your child may discontinue the survey or skip any or all questions on the survey without penalty or loss of any benefits to which they are otherwise entitled. The group mentor will administer the survey during the first and last session of the program. All responses are completely anonymous and confidential. Responses are reported for groups of youth and cannot be linked to any individual youth. You can review a copy of the survey online at https://www.voaut.org/preventionservices*
Yes, my child may take the survey.
No, my child may not take the survey.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Gender*

Please specify a gender identity not listed...
Race/ Ethnicity *
Hispanic / Latino (of any race)
Native American / Indigenous
Black / African American / African
Asian
Native Hawaiian / Pacific Islander
White / Caucasian
Bi-Racial or Multi-Racial
Race/ ethnicity not listed here

Please specify a race/ ethnicity not listed...

Youth's School *
Grade*

Youth's Email (if applicable)

Youth's Phone Number (if applicable)
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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