Ohio Healthy Youth Environments Survey – OHYES!

Ohio Healthy Youth Environments Survey – OHYES!
PARENT OPT-OUT FORM – for youth 12 – 17 years old

Youth under 12 years of age are not eligible to participate

Parental consent is not required for youth aged 18 and above

A separate form must be returned for each child not participating.
Student Full Name

First NameLast Name
Student Grade
Parent Full Name

First NameLast Name
Email (if applicable)
example@example.com
Phone Number (if applicable)
Please enter a valid phone number.
Mailing Address (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NO, my child may not participate in the OHYES! survey
Date

MonthDayYear
Date
Signature

Clear
Should be Empty: