Pride Survey Permission Form

Dear Parent or Guardian,

Substance abuse is the number one public health issue facing youth nationwide.
The Center for Prevention and Counseling, in collaboration with the Sussex County Charter School of Technology, will be administering a survey of students in grades 9th to 12th on their attitudes and behaviors regarding tobacco, alcohol and other drugs. This information will help in the evaluation of current drug prevention programs and assess the need for new and/ or modified programs. You can visit for a sample questionnaire and more information about the company itself.

The data collected from these surveys will NOT allow for analysis of any individual student.
The survey collects data that provides an overview of youth’s knowledge regarding tobacco, alcohol and other drugs. Students responding to Pride Surveys are assured anonymity. There is no interviewer, no place on the questionnaire to provide a name, and no other means to identify a respondent.

No one will ever know how any individual responds to the survey. School staff members will not see the surveys when they are completed. Students will not put their names on the surveys. Upon completion, students put their surveys into envelopes which are boxed and shipped to the research firm where the results are compiled. In addition, students will be free to refuse to answer any questions simply by leaving the answers blank on the survey.

The questionnaire will take about 20 minutes. NJ State Law requires a guardian’s permission for a minor. You can provide permission for your child to take the survey by signing and returning this form to the school.

Thank you for your help as we all work together to keep youth healthy, safe and drug-free.

Email address *
Student's Name *
Your answer
Student's Grade *
PARTICIPATION: I understand that my child's participation in this survey on alcohol and other drug use is voluntary and that I may withdraw my consent at any time before the class period when the survey is given.PLEASE CHECK YES OR NO BELOW, SIGN AND RETURN TO SCHOOL: *
Signature of Parent or Guardian
Your answer
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