WI Wins Youth & Adult Consent Forms

WI Wins Youth & Adult Consent Forms

Application and consent form for participation in the WI Wins Tobacco Compliance Check Program. Please complete all relevant sections.
Dear Youth Participant and Parent/Guardian,

My name is Emily Longmeyer-Wolf, and I serve as a Social Worker and The Lakeshore Tobacco Alliance Coalition Coordinator at Northeastern Wisconsin Area Health Education Center (NEWAHEC). In this role, I lead our local implementation of the WI Wins program, a statewide initiative focused on reducing youth access to tobacco and nicotine products by ensuring retailers comply with established laws and regulations.

We are currently recruiting youth to assist with tobacco compliance checks.

What Is WI Wins?
- WI Wins trains youth to serve as Youth Inspectors who, under the supervision of an adult, visit tobacco retailers and conduct compliance checks. These checks are legal, confidential, and safe, and they are conducted following strict protocols. Youth inspectors can be 16 or 17 years old.
- Each check involves two youth inspectors: One youth attempts to purchase a tobacco or vape product.
- The second youth observes the interaction and takes mental notes.
- Before heading out for checks, we conduct a brief training session to review the procedures and ensure everyone is comfortable and prepared.
Key Details:
- Pay: Youth are paid $10/hour, with payment issued in a lump-sum check after their assigned checks are completed.
- Meals: Lunch is provided on the day of the checks.
- Scheduling: Checks are typically done in 4–5-hour blocks on non-school days.
- Supervision: A trained adult is always present during every check to ensure safety, support, and is the designated driver of the inspectors.
- Counties & Check Requirements: We conduct checks in Manitowoc, Sheboygan, Door, and Kewaunee Counties. WI Wins requires that we check at least 60% of tobacco retailers in each county.

Participant Information
Full Name

First NameLast Name
Gender

Other Gender Identity
Preferred Pronouns
Current Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
School Email Address
example@example.com
Preferred method of contact
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
High School
Previous employment and/or community and school activities (include full or part-time employment, volunteer positions, clubs, church groups, sports, school clubs, etc.)
Do you use tobacco products (cigarettes, cigars, smokeless, e-cigarettes)?
Have you ever participated in anti-tobacco programs, projects, or events?
Participant Certification
I hereby certify that to the best of my knowledge the above information is true.
Date

MonthDayYear
Date
Parent/Guardian Consent
Parent/Guardian Name

First NameLast Name
Parent/Guardian Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I give my consent for my child to participate in the retail tobacco compliance check survey, which will require my child to purchase tobacco products under adult supervision.
Date

MonthDayYear
Date
I would like to be a parent/guardian participant and will accompany my child.
Emergency Medical Consent
Participant Name

First NameLast Name
Participant Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
I hereby give my consent to have the above-signed participant treated by a physician or surgeon at my expense in the case of a sudden illness or injury while participating in the retail tobacco compliance check survey activities. If a personal physician is listed below, every effort will be made to contact that physician. However, the location of the activity or the nature of the illness or injury may require the use of emergency medical personnel.
Parent/Guardian Signature (for emergency medical consent)
Date

MonthDayYear
Date
Name of Family Physician or Medical Group
Physician or Medical Group Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Insurance Coverage and/or Medical Group Number
Should be Empty: