Decision-Not-to-Participate-Form

Decision Not to Participate Form
CYBER ID
Youth Name*
Parent/Guardian Name*
Youth Date of Birth*

MonthDayYear
Date
Youth Age*

Youth is under 14yrs oldYouth is 14 yrs or olderYouth is their own guardianYouth is over 18 but is not their own guardian
NOTE: Due to Youth being over 14 years of age, they are required to sign the record request form. Please ensure they are available to sign the following form prior to submission.

Decision Not to Participate Form