Clone of 2025-26 HelpLine DC-YLC Parent Permission Form

HelpLine DC-YLC 2026-27 Parent PermissioN Form
HelpLine is excited to offer the Delaware County Youth-Led Council (DC-YLC) for a second year! Your student has expressed interest in learning more about DC-YLC.

Please complete the form to permit the HelpLine Prevention staff to contact your child with additional information.

Thank you for your support!

Questions?

Questions? Contact Brittany Wolf-Delawder, Youth Engagement Coordinator at bwolfdelawder@helplinedelmor.org.
- Full Name of Student
  
  First NameMiddle NameLast Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Name
  
  First NameLast Name
- Relationship
  ex. Father, Mother, etc.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Signature
- Parental Permissions
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Emergency Contact
  
  First NameLast Name
- Relationship
  ex. Father, Mother, etc.
- Emergency Contact Email
  example@example.com
- Emergency Contact Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Please verify that you are human
- Should be Empty: