SAFE HOMES in the Triad Parent Pledge

1. As a Safe Homes parent, I am committed to helping keep our teens safe and encouraging them to have fun in safe & appropriate ways. I agree that:

I will NOT allow unsupervised parties or gatherings in my home.
I will NOT serve or allow anyone under the age of 21 years to consume alcohol, or permit the use of illicit drugs by anyone in my home or on my property.
If there are firearms in my home, I will secure them adequately to make sure that they are inaccessible to my teens and their guests.
I wish to be informed by other parents of any alcohol or drug use or any other risk taking behavior of which they are aware my child/children may be involved, and I will do the same for other parents.
Whenever possible, I will call other parents for information when my child/children is/are invited to a party, and I will welcome calls from other parents concerned about their child/children.
I understand the SAFE HOMES in the Triad shares some information with other pledging parents as part of helping each other. I know that, at the time I sign the pledge, I will be able to electronically control the amount of information made available, and I know that I can change my options at any time.

	Yes
	No

2. I understand that I am entitled to decide exactly how much information is shared with other parents and that ONLY the information I define will be shared. I agree to allow disclosure of ONLY the following information: Required Question

3. This private information may be released as follows: Required Question

	To all parents who sign the SAFE HOMES in the Triad Parent Pledge
	Only to parents whose children attend the same school as my child(ren)

4.

Parent(s) First Name(s)

Parent(s) Last Name(s)

Street Address

Apt/Suite/Office

City

Zip Code

Email Address

Phone Number

Mobile Phone

5. Name of Teen #1 (If you designated above that you do not want your child's name published, that request will be honored and their name will be protected.) Required Question

6. School(s) attended by Teen #1 (remember to include the Career Center, FTCC, etc. if applicable) Required Question

7. Graduation Year of Teen #1 Required Question

8. Name of Teen #2 (If you designated above that you do not want your child's name published, that request will be honored and their name will be protected.)

9. School(s) attended by Teen #2 (remember to include the Career Center, FTCC, etc. if applicable)

10. Graduation Year of Teen #2

11. If you have more than 2 children in high school, please note their information as well. (If you designated above that you do not want your child's name published, that request will be honored and their name will be protected.)

12. SAFE HOMES Projects that are successful are those that are parent-driven. Are you willing to serve as a SAFE HOMES Parent Representative for your teen's high school for the remainder of this school year and the next school year? Time commitment is likely to be less than 3 hours per month and perhaps even less.

	Yes
	No
	Maybe, please contact me to discuss this

13. I wish to receive information and materials about the following subjects:

14. I have concerns about someone I know who needs help related to their use of alcohol, medications or drugs. Please have someone contact me privately.

	Yes. Please contact me by phone.
	Yes. Please contact me by email.
	No.

	Parent(s) Names
	Teen(s) Names
	Schools Attended
	Street Address
	Home Phone Number
	Mobile Phone Number
	Email Address

	Underage Drinking: Myths & Facts
	The Role of Parents in Preventing & Addressing Underage Drinking
	Tips for Teens: The Truth About Alcohol
	Awareness of Youth Use of Cigarettes, Alcohol & Marijuana
	What You Need to Know: The Effects of Alcohol on Women
	Getting High on Prescription & OTC Drugs: Keeping Your Teen Safe in a Changing World
	When It's Not Your Kid, How Do You Deal With Drug and Alcohol Use? (Early Intervention Adult Influencer brochure)
	Wake Up to the Risks of Marijuana: A Guide for Parents
	Materials about Local Resources for Substance Abuse Treatment
	Materials about Local Resources for Drug Testing
	Materials about Full Life Counseling