New Haven Youth & Family Services

Consent to Participate in Family Life Program


Youth Name: ____________________________________

Date of Birth: ___________________________________


New Haven Youth and Family Services provides a Family Life Program to the youth in our educational and residential programs. The Family Life Program offers youth an opportunity to learn and discuss important topics such as: healthy relationships, disease prevention including the prevention of Sexually Transmitted Diseases, responsible parenting, and dealing with grief and loss.

This program is provided to all residents who are able and willing to participate unless the parent or legal guardian of the youth denies consent to participate.

I am affirming that the above named resident has my consent to participate in the New Haven Family Life Program.


___________________________________/ _________

Signature of Parent, Guardian, or Authorized Representative/ Date


___________________________________/ _________

Signature of NHYFS Representative or Witness/ Date