Youth Group Consent Form Youth Group Activity Consent Please complete this form to consent to your child's participation in social / support group activities. Child's Information Child's Name * Child's Date of Birth * Youth Group Activity Permission San Francisco Speech and Fluency Center periodically provides opportunities for children and adolescents who stutter to get together in person or online using a secure online conferencing platform. Providing an opportunity for young people who stutter to get together can be a vital part of their growing acceptance of their stutter. Although formal speech therapy is not a component of these activities, many find it beneficial. By signing below, I, being the parent or legal guardian of the youth named above, do hereby consent to the participation of my youth in online or in-person social activities hosted by San Francisco Speech and Fluency Center. If I wish to revoke this consent for any reason, I will notify Bailey V. Levis, CCC-SLP, owner San Francisco Speech and Fluency Center, by email or snail mail. San Francisco Speech and Fluency Center has my permission to email my child for the purpose of arranging youth group activities * Yes No I would like to be CC'd on all emails sent to my child / teen. Emails will be sent to the parent / guardian at the address listed below. * Yes No My Child's / Teen's Email * Signature Required Your Name * Relationship to Client * Parent Guardian Other Relationship to Client Signature * Clear Enter your email to receive a copy of this authorization Entering your email does not add you to any mailing lists. Your information is never shared. Confirm Enter your email to receive a copy of this authorization reCAPTCHA Submit If you are human, leave this field blank.