I-PLEDGE FY24 Consent Form

► I understand my participation is voluntary and I will be under the supervision of a law enforcement

officer at all times.

► I understand it is essential to maintain the confidential nature of the program, therefore ensuring the

effectiveness, accuracy and validity of the outcome.

► I understand my participation in the project can be terminated at any time by myself, a parent/

guardian (if under age 18) or the law enforcement agency.

► I understand compliance checks may result in the purchase of tobacco, alternative nicotine and va-

por products. I understand tobacco, alternative nicotine and vapor products will be treated as evi-

dence and maintained by the law enforcement agency.

► I understand that I may be required to enter bars.

► I understand retailers in violation of minimum-age tobacco, alternative nicotine and vapor product

laws may receive citations that result in monetary fines, suspension or revocation of their license and

that I may be asked to participate in the adjudication process.

► I understand the success of the project is not dependent upon making successful, illegal purchases.

My signature on this document verifies my willingness to participate in the project and to follow the rules

and procedures outlined in the training.

Underage Purchaser Signature ____________________________ Date __________________

I have read the Program Procedures and Underage Purchaser Guidelines and give my permission for

my child to participate in this project.

Parent/Guardian Signature _______________________________ Date __________________

Program Coordinator ___________________________________ Date __________________

Note: Parent/Guardian signature is not required if the underage purchaser is over the age of 18.

VII. Underage Purchaser Consent Form

FY 2024

Underage Purchaser’s Name: _________________________________________________________________________

Address: ___________________________________________________________________________________________

City: _____________________________________ State: ______ Zip: ________________________________________

Home Phone Number: _________________________ Date of Birth: __________________________________________

Social Security Number: ____________________________ Gender: _________________________________________

Underage Purchaser’s Driver License or Identification Card No.: ____________________________________________