Medford, Massachusetts

Dear Parent or Guardian:
Our school will be administering a survey to its students. This survey is designed to improve our
understanding of adolescent alcohol, tobacco, and other drug use, as well as adolescent crime, delinquency and
related problem behaviors. Our goal in better understanding these behaviors is to more effectively target our
efforts to prevent them. The survey is sponsored by Team Medford and Medford Health Matters in
collaboration with the Medford Public Schools. It is funded by a grant from the federal government.
We want to make sure that all parents are notified about the survey being conducted and provide as much
information about the survey as possible. As a parent, you have the right to prohibit your child’s participation.
The following are facts about the survey to help you make an informed decision about your child’s
participation in the survey.
1. It is voluntary. Your child does not have to participate. Neither you nor your child is required to give a
reason for not participating. Students who do participate will not be required to answer all of the questions
– only those that they choose to answer.
2. It is anonymous and confidential. The survey is designed to protect your child’s and the school’s privacy.
No names or other identifying information will be recorded. Once completed, all of the surveys will be
carefully protected. After six months, the surveys will be destroyed.
3. It is well tested. The survey, developed in the early 1990’s has been given to over 500,000 students in the
United States. The information from the survey has been used to prevent a variety of adolescent problem
A copy of the survey is available for you to review at your school. You may also call Brooke Hoyt at
(781)393-2449 with the Medford Health Department for more information.
The results obtained from the survey are more likely to be accurate and precise if more students participate.
Therefore, we urge you to allow your child to participate in this important survey. You do not need to notify
the school or sign anything to allow your child to participate. If you do not want your child to participate,
you must complete the attached form and return it to the school. If you decide to prevent your child’s
participation, he or she will be given an alternative activity for the survey period.
Thank you for your cooperation. This survey plays an important part in our efforts to prevent substance use,
delinquency and other kinds of adolescent problem behaviors. We hope you will allow your child to

Toni B.Vento, MS, RN, NCSN
Supervisor of Health Services

Rachel Perry, MS Athletic Administration
Lead Teacher, Health and Physical Education

Parent (s) or legal guardian: Please check and sign below, and return this form to the school if you do not want
your child to participate in the Communities That Care Youth Survey.
____I do not give consent for my child, ______________________________, to participate in the survey
being conducted at _______________________. Please provide him or her with an alternative activity while
the survey is being administered.
Signature: ___________________
Date: _______________________