YAG Participation Consent Form (Minor)

For a Minor with Parent/Guardian

We are excited that your teen is interested in participating in the Breaking the Silence New Mexico (BTSNM) Youth Advisory Group. BTSNM is a non-profit organization dedicated to reducing the stigma and secrecy around mental health, suicide, and bullying. We provide free mental health lessons to schools and communities across the state. The Youth Advisory Group plays an important role in this mission, primarily by advocating for mental health awareness for all. Members share their perspectives on our curricula, participate in mental health workshops and trainings, and engage in outreach and promotional activities. Through their involvement, youth not only contribute to a stronger culture of mental health awareness in New Mexico, but also gain valuable lifelong skills that can carry forward.

• Participation in the program is completely voluntary.
• Participation in the group will involve attending one (1) meeting per month (in-person and/or virtually), workshops, and/or community engagement events, for up to 4 hours monthly.
• Participation of youth under the age of 18 requires a parent/guardian review and consent to participate.
• Youth benefits include service hours, letters of recommendation, and possible monetary rewards, such as scholarships and gift cards.
• BTSNM requests a one-year commitment from selected students, with the option to reapply in future years.

PERMISSION TO PARTICIPATE

I hereby permit minor named below to participate in the BTSNM Youth Advisory Group. I understand that the information discussed is intended to provide a better understanding of youth mental health education. I agree to let the group facilitators know if there are any topics that might be of concern. In case of an emergency, I will be reached at the phone number I list below.

MEDIA RELEASE

Participants in the BTSNM Youth Advisory Group may be photographed or videotaped for use in promotional, educational, and advocacy purposes. Such audio, video, film, and/or print images may be edited, duplicated, reproduced, broadcast, and/or reformatted in any manner without payment of fees. I authorize the use of the participant’s image to be used in any media for lawful purposes.

"*" indicates required fields

Email

This field is for validation purposes and should be left unchanged.

Consent*

CONSENT: I hereby certify that I am the parent or guardian of the below-named minor and do hereby give my consent without reservation to the foregoing on behalf of my minor.

NON‐CONSENT: I hereby certify that I am the parent or guardian of the below-named minor and do not hereby give my consent without reservation to the foregoing on behalf of my minor.

Minor's Full Name*

Minor's DOB*

MM slash DD slash YYYY

Parent/Guardian Signature*

Parent/Guardian Name*

Parent/Guardian Phone*

Parent/Guardian Email*