SMART Moves Permission Form
Dear Parent/Guardian,

The Basement Teen Center (BTC) will soon be implementing the SMART Moves program, and we would like your permission for your child to participate. The SMART (Skills Mastery and Resistance Training) Moves program is a prevention and education program designed to address issues such as drug and alcohol abuse and sexual activity. The curriculum we will be using is called Stay SMART and is designed for 13-15 year olds, though the course is open to 12-18 year olds. The class is led by myself and the BTC’s AmeriCorps member, Mariana Wilson. The course will start on January 9th and will be every Wednesday and Thursday from 4:30pm-6pm until January 31st. Upon successful completion of the course, participants will receive a $75 stipend check.

Young people today are faced with so many messages – in the media, from their peers, and in the world around them – encouraging them to engage in unhealthy behaviors. This program is designed to teach how to say “no” by involving them in relevant discussions and activities to learn resistance and refusal skills, as well as how to develop assertiveness, strengthen decision-making skills and analyze media and peer influences.

Please note that your child may wish to talk to you about some of the topics we’ll address, including: decision-making and problem-solving; drugs, alcohol, and tobacco use; adolescence and puberty; relationships, intimacy and sexuality; peer pressure, bullying and media literacy; and family and community. As this program will discuss sensitive subject matter, including sexual content, please let me know if you would like to review the appropriate program guide in advance.

Please sign below to give your child permission to take this course, and please email me to let me know that your child plans to take this course so I can reserve them a spot. Should you have any questions, I can be contacted at the number and email address below. Thank you for your time and support.


Paul Eley
Director, Basement Teen Center

Youth Name *
Your answer
Permission to Participate *
Parent/Guardian Signature *
Your answer
Date Permission given *
We may need to postpone a class session due to weather, illness, or some other compelling reason. Please provide an email address or phone number to receive updates (email preferred). *
Your answer
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