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Kids Interacting Drug-free and Teen Anti Drug Coalitions of America, Coalition Pathways™
Parental Consent Form
INSTRUCTIONS: Please review the information
provided on this form, fill in the information below, sign the bottom and fax it to (814) 453-4714, or mail it to:
If you have any questions, please feel free to call the offices of Coalition Pathways Inc. at (814)-833-2944 or email ndrexler@coalitionpathways.com
When Coalition Pathways Inc. receives this completed information sheet, and this consent form is signed by the
parent or lawful guardian, your child will be signed up to receive the www.epeervoices.com website emails. The short emails contain a message with an anti-drug focus, and the emails will provide youth with specific projects,
activities, and resources they can use in their community or school, as well as important anti-drug information. Coalition Pathways is a non-profit, 501-c-3 organization dedicated to reducing underage drinking, teen tobacco
use, illicit drugs and drug-related violence. If you have any additional questions, please feel free to call (814) 461-6644 or send an email to ndrexler@coalitionpathways.com
I, _____________________________________ (Name of Parent or Lawful Guardian),
hereby certify that I am the parent and/or lawful guardian of
____________________________________________________ (Child's Name).
Child's First and Last Name: (Please Print) _____________________________________________
Street Address_____________________________________________
City, State Zip Code_____________________________________________
Age of child_____________________________________________
Youth Email address:_____________________________________________
Ethnicity: (Optional)_____________________________________________
How did you learn about us?_____________________________________________
Privacy Statement: I understand and agree that when I register my child for the www.epeervoices.com
web site to participate in its broadcast emails, discussions, surveys, contests or games, etc. that Coalition Pathways Inc.,
or its authorized agents, may collect and maintain the above stated information about my child, but no disclosure or release of covered information will be made to any third parties or the public in any format for any purpose
without advance express written consent of the participating individual and his/her parent or guardian. (The information is maintained for tracking purposes only, and for identifying age ranges and the geographic regions
participating in the emails. Coalition Pathways Inc. is a non-profit, 501-c-3, scientific research-based, national CSAP Exemplary Award Prevention Program, focusing on youth empowerment. Registered participants may
cancel by unsubscribing to their www.epeervoices.com emails at any time.)
I have read and reviewed the above information and the Privacy Statement and I give my permission for Coalition Pathways Inc. to collect, use and disclose personal information about my child in accordance with the terms stated
therein, consistent with the Privacy Act, 5 U.S.C. 552(a), and the Freedom of Information Act, 5 U.S.C. 552.
_____________________________________ ______ ______________________________________
Signature of Parent or Lawful Guardian Date Adult Email address (parent email) if available
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