HHCC - Parent Pledge Form

Jennifer Lehman, Program Coordinator

Henry County Extension

127 N. Main

Mt. Pleasant, IA 52641

319-385-8126

lehmanj@iastate.edu

The Henry County Substance Abuse Coalition
invites you to take the Parent Pledge.

The Parent Pledge provides parents with an opportunity to engage in constructive, positive practices and change community norms around adolescent alcohol and other drug abuse.

The Parent Pledge, promoted by the Henry County Substance Abuse Coalition (HCSAC), states that parents will not supply or permit in their homes, the use of alcohol or abuse of other drugs, including over-the-counter drugs by minors. The goal of the Parent Pledge is to create a visible network of drug-free homes in Henry County.

You can submit the Parent Pledge online below or you can print a hard copy of the Parent Pledge and send it to the HCSAC by mail.

We invite you to join other concerned parents in creating a healthy, drug free lifestyle for youth by signing the Parent Pledge, which states:

"I will ensure that all social events in my home for teens are chaperoned
by a parent and that I will not serve alcohol or other drugs to be used by teens.
I also agree to inform my son or daughter that I have signed this pledge."

**Asterisk indicates a required field.*
*Parent(s) Name(s):	Your name is required.
*Street Address:	An address is required.
*City:	A city is required.
*Zip Code:	A zip code is required.
*Home or Cell Phone: ex. 333-333-3333	A phone number is required.
Email:
How many students are you pledging for?
*Name(s) of student(s):	Student name(s) are required.
*School District:	A school district is required.
Please select Yes or No	I grant permission to Henry County Substance Abuse Coalition to list my contact information (name & phone number only) in the Parent Pledge Directory. I will be sent a Parent Pledge Directory.

Please verify your information before you click 'Submit'.