Chaperone Authorization and Emergency Contact Document
Participant Information
Name:
Date of Birth:
Address:
Parent/Guardian Information
Name:
Phone:
Email:
Chaperone Authorization
Chaperone Name:
Relationship to Participant:
Chaperone Phone:
Authorization Notes:
Emergency Contact
Contact Name:
Phone:
Relationship:
Medical Information
Allergies/Special Conditions:
Other Comments:
Parent/Guardian Signature:
Date: