Youth Mental Health Ambassadors Registration and Permission Form

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Student Name Student Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Current School Name
Grade
Parent or Caregiver Name Parent or Caregiver Name First Last
Relationship to Student
Parent or Caregiver Phone Parent or Caregiver Phone - ### - ### ####
Parent or Caregiver Email
Program Site/Dates
Emergency Contact Name Emergency Contact Name First Last
Emergency Contact Phone Emergency Contact Phone - ### - ### ####
Please review and check each statement

Please review and check each statement I received and read the program description and had an opportunity to ask questions. I understand that the course discusses mental health, substance use, self-injury, suicide, violence and other sensitive topics in an age-appropriate, non-graphic way. I understand that this program includes the official tMHFA course and the MHAOC Youth Mental Health Ambassador extension. It is education and leadership development, not therapy, diagnosis or crisis treatment, and participants are not trained as counselors or crisis responders. I understand that participation is voluntary. My teen may ask questions, pass on an activity, request support or withdraw. A missed meeting may be made up at the other location with advance coordination, but all four meetings are required for both certifications. I understand that staff must act when there is a safety concern, suspected abuse or neglect, or another situation requiring mandated reporting or emergency response. Staff may contact me when appropriate. I give permission for brief, nonclinical pre/post questions and skill activities used to improve the program and report grant results. Responses may be linked by a participant code and reported only in summary form.
Permission decision

Permission decision YES. I give permission for my teen to participate in Youth Mental Health Ambassadors, including the official teen Mental Health First Aid course and the MHAOC ambassador extension. NO. I do not give permission for my teen to participate.
Photo Consent

Photo Consent I give my permission for MHAOC to utilize pictures of my child during YMHA activities on social media, website and other promotional materials. I DO NOT give consent for MHAOC to utilize pictures of my child.
Support or accessibility information - Please share allergies, accessibility needs, accommodations or other information staff should know to support safe participation. Do not include private clinical details unless they are needed for safety.
Parent/Caregiver - Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Youth assent

To be completed by the student participating in YMHA
I understand what this program is about. I know I may ask questions, pass on an activity, request support or step out with an adult. I agree to follow the group agreements and safety expectations, and I want to participate.

I understand what this program is about. I know I may ask questions, pass on an activity, request support or step out with an adult. I agree to follow the group agreements and safety expectations, and I want to participate. I agree with this statement.
Student Signature - Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Youth Mental Health Ambassadors Registration and Permission Form

Youth Mental Health Ambassadors Registration and Permission Form

Youth assent