Fillable Parent/guardian Information and Consent Form regarding Health and (35th Force Support Squadron)

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Parent/guardian Information and Consent Form regarding Health and (35th Force Support Squadron)

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Parent/guardian Information and Consent Form regarding Health and Life Skills
According to the Youth Programs Air Force Instruction guidance, youth shall be offered daily
opportunities to engage in positive behaviors that nurture their own well-being, set personal goals,
and develop the competencies to live successfully as self-sufficient adults.
The Lunney Youth/ Misawa Teen Center offers a variety of programs and activities to help youth
with money management, healthy lifestyle, hygiene, communication, personal goal setting,
independent living, and nutrition. Youth are encouraged to engage in programs to increase their
nutritional awareness and support positive behavioral change including, but not limited to SMART
Moves, SMART Girls, Passport to Manhood or similar programs that develop their skills to resist
alcohol, tobacco, and other drug use as well as other risk-taking behaviors.
The Lunney Youth/ Misawa Teen Center often partners with other community agencies on healthy
lifestyle educational sessions or special events such as health fairs to provide youth and their families
with resources to make healthy choices. Programs, activities, conversations, and display materials are
designed to be outcome-driven to address age-specific milestones in the area of healthy lifestyles.
Please review the below list of topics which may be covered in health and life skills activities:
Physical and emotional growth in adolescence
Puberty (Girls and boys will separate during this lesson)
Media influences and body image
Eating disorders
Personal values and social interactions
The importance of preventative healthcare (i.e. Check-ups)
Sexual orientations (Girls and boys will separate during this lesson)
Healthy relationships between friends and family
Respecting authority
Anger/stress management
Understanding, acknowledging, and reporting abuse (Girls and boys will separate during this lesson)
Some lessons may also include watching movies rated G, PG, or PG-13 which are related to the
topics mentioned above, such as “Big”, “13 Going on 30”, “Inside Out”, for example.
_________ I DO give permission for my youth to participate in activities related to the above topics;
with the exception of (please circle the above topics you DO NOT give permission for
your youth to participate in.)
OR
_________ I DO NOT give permission for my youth to participate in ANY activities related to the
above topics.
___________________________________________
Parent/guardian Signature & Date
Military and Family Life Counseling Program
Parent Consent Letter, August 2018
Parent Consent Letter
From:
[Insert name of installation, school, camp, facility]
Subject: Child and Youth Behavioral Military and Family Life Counselor
1. is letter is to inform you about Military and Family Life Counseling Program services. Due
to the unique challenges faced by military families, the Department of Defense is oering
this private and condential non-medical counseling service to military service members
and their families, including children, through child and youth programs, Department of
Defense Education Activity schools, local education agencies, DoDEA and CYP summer
programs, National Military Family Association Operation Purple Camps, Guard and reserve
camps, and Operation Military Kids camps.
2. Child and youth behavioral military and family life counselors, or CYB-MFLCs, may provide
support in Military and Family Support Centers, schools, summer programs and camps.
ey work with military children and their families in the following ways:
•
Observe, participate and engage in activities
•
Interact directly with military children
•
Model behavioral techniques and provide feedback
•
Suggest courses of age-appropriate behavioral interventions to enhance coping and
behavioral skills
•
Reach out to military parents when convenient, such as when they drop o or pick up their
children or at family events
•
Be available for military parents to contact for guidance and support
•
Facilitate psychoeducational groups
•
Conduct training for sta and parents
•
Recommend referrals to military family programs and other resources as needed
3. Counselors may assist military parents and children with the following types of issues:
•
Communication
•
Self-esteem and self-condence
•
Conict resolution
•
Behavioral management techniques
•
Bullying
•
Anger management
•
Sibling and parental relationships
•
Deployment and reintegration issues
Misawa Teen Center
Military and Family Life Counseling Program
Parent Consent Letter, August 2018
4. Counselors may also work with military children on eld trips and during camp or school-
sponsored activities.
5. Counselors are available to accommodate appointments, meetings and activities after hours
and on weekends with advance notice.
6. At no time will a counselor meet individually with a child without being in line of sight of a
program employee or a parent or guardian.
7. Counselors may use only OSD-approved materials for trainings, groups and other activities.
8. With the exception of mandatory state, federal and military reporting requirements
(for example, domestic violence, child abuse and duty-to-warn situations), as well as
oversight review by the Department of Defense of the service you received should an
adverse or harmful event occur, MFLC Program support is private and condential to
encourage the greatest level of participation.
Print name of child:
Check only one box below:
I understand the above CYB-MFLC Program description and authorize my child to
participate in CYB-MFLC services. is authorization is valid for the duration of my
child’s enrollment. I understand I can revoke this authorization at any time in writing.
I do not authorize my child to participate in CYB-MFLC services.
Parent or guardian signature Date
click to sign
signature
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Child and Youth Programs Flight
Payment Agreement and Credit Card Autopay Authorization
Child(ren) Last Name, First:
Name
of Sponsor___________________________________☐ADAF ☐AD Other ☐DOD Civ ☐Other
Cell Phone:______________________________ Duty Phone: _____________________________
Email Address: _______________________
Program Site: CDC
SAC Youth Programs
Program Services: (select all that apply)
Full Day CDC Part-day Preschool
B
efore
& After
Before School A
fter School
Instructional Class/ Sport/ Hourly
Payment Schedule: 1
st
of Month 1
st
& 15
th
of Month Weekly (SAC/ PDE Only)
Would you like to enroll in Auto Pay?
Yes. By selecting yes, I understand that Chase Paymentech Orbital online system will automatically charge
my card per my payment schedule. If my payment declines, and fees not paid by 1730 on my payment
schedule I will be charged an additional $5 per day late fee.
No. By selecting no, I understand that I will have to make a payment to the front desk on my payment
schedule. Fees not paid by 1730 on my payment schedule will be charged to the credit card on file. If the
payment declines, I will be charged a $5 per day late fee. By selecting no, I understand that I still have to
provide a credit card to be kept on file.
By signing below, I authorize the Child Development Center, School Age Care or Youth Programs to
automatically charge my account for any balance due for services I have agreed to pay as stated above.
Signature
Date
This document contains personal data subject to the Privacy Act of 1974, 10 USC 8012 & EO 9397.
Requires safeguarding and disclosure only as authorization in AFI 33-332. CONFIDENTIALITY APPLIES.
-----------------------------------------------------------------------------------------------------------------------------------------
Credit Card Number:
Type of Card: Club Card Master Card
Visa
Mastercard
Cardholder Name (as it appears on the card):
3 Digit CVV Code: Expiration Date (MM/YY): Billing Address Zip Code
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Parentguardian Information and Consent Form regarding Health and (35th Force Support Squadron)

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Completed 25 July 2021

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