Neighborhood Safety Net Permission for Services

The Neighborhood Safety Net (NSN) is a team of agencies and organizations collaborating to offer a broad range of services to advance the emotional and social well-being of youth. NSN focuses on the individual, providing support tailored to personal learning and career goals.

Your permission is needed to enroll your child. Once enrolled, your son/daughter will be able to access the services offered by NSN and its partners.

Your consent is also needed so the agencies and organizations involved can share health, services, and educational information in order to serve your child in the best possible way.

By checking this box, I,	(Name of Parent/Guardian)
give permission for	(Name of Youth)

to be enrolled in, and access the services, of NSN agencies and organizations. I also give consent to NSN to share information from my child’s health, education, and services records among its agencies and organizations.

I further acknowledge that this permission will remain in effect until my child is released by NSN or until I, the parent/guardian, withdraw permission in writing. I further understand that unless I provide additional written permission, NSN agencies and organizations cannot release any information about my child to a third party.
If there is any agency that you DO NOT want to work with your child, please list the name of that agency in the space provided below.

Please provide the following additional information:

Parent/Guardian Name	Date


Street Address	Phone Number

City	State	Zipcode
Rochester	NY