Peer Education Program • Parental Consent Form

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Your daughter/son is applying for a position as a Peer Educator with Planned Parenthood of Indiana and your signed consent is necessary for us to process the application. This application and consent form must be returned to Planned Parenthood of Indiana before we can proceed with the application process. If you have any questions or concerns, please do not hesitate to contact us at the number or email address below.

I understand that my daughter/son _______________________________(name) is applying to the Planned Parenthood of Indiana Peer Education Program and I, the undersigned:

1. Hereby state that the above-named minor has my permission to apply for and participate in the Peer Education Program sponsored by Planned Parenthood of Indiana.
2. Consent and give permission to you and those acting under your authority to use the above-named minor's personal story and photograph as a medium for advertising, marketing or communications as you may choose throughout the world and I consent and give you permission to use the above-named minor's name and biography in connection therewith. I waive the opportunity and right to inspect or approve any such communications or any use to which they may be put. I release Planned Parenthood of Indiana, its officers, members, directors, agents, employees, and those acting under its authority, from all debts, claims and liabilities of any kind arising out or in connection with the making or use of such communications or the use of the above-named minor's name or biography;
3. Understand that the above-named minor's services as a Peer Educator will be offered on a voluntary basis without anticipation of financial remuneration;
4. Shall indemnify and hold harmless Planned Parenthood of Indiana from and against all claims, demands, losses or liability or against any kind or nature of possible injury incurred during the above-named minor’s volunteer services, including during travel to and from volunteer activities;
5. Understand that it is Planned Parenthood of Indiana's mission to Protect, Provide and Promote Reproductive Health for all and that it is Planned Parenthood of Indiana's goal to accomplish its mission through providing reproductive health services, advocacy and education services.

Please print out and return the completed consent form and application to:

Peer Education
Planned Parenthood of Indiana
200 South Meridian Street, Suite 400
Indianapolis, IN 46225
Phone: (317) 637-4140
Fax: (317) 637-4141
peer.ed@ppin.org