The following is an example of a permission form that students will receive prior to any participation in the Canadian Student Tobacco, Alcohol and Drugs Survey (CSTADS).  This example form is for reference only; actual forms will include school and class specific information.

Please do not use this example in place of an actual permission form.

Permission Form

Please complete this Permission Form if you DO or DO NOT want the student to take part in this survey. If the student is (XX years old) or older, they can decide on their own if they want to participate in the survey. Students MUST have a returned permission form, indicating permission, in order to participate. Please keep the rest of this letter for your records. 

COMPLETE ONLINE at http://cstads.ca/permission (code: [school specific code for online permission forms])
OR
RETURN THIS FORM to your child's classroom
OR
SCAN QR CODE and complete on your mobile device. [class specific QR code] 

STUDENT'S SCHOOL: [School Name]/ [School ID Number]

ONLINE CODE: [Online Access Code]

CLASSROOM TEACHER: [Teacher Salutation Name]

This is NOT my classroom teacher.
My teacher's name is:________________________________________
(please print)    

NAME OF STUDENT:
(print in capitals)

First:
Last:

STUDENT'S GRADE:

NAME OF PARENT/GUARDIAN:
(print in capitals)

First:
Last:

Permission Decision
(please check ONLY one) 
YES, I (parent/guardian) give permission for my child to participate. 

OR

YES, I (student) am STU_AGE or older and AGREE to participate. 

NO, I (parent/guardian) DO NOT give permission for my child to participate. 

OR

NO, I (student) am STU_AGE or older and DO NOT AGREE to participate. 

SIGNATURE/DATE:

Signature:

Date: