Parental Consent Form
Nonprofit Youth Program
Program Name
Program Date(s)
Youth Participant Information
Full Name
Date of Birth
Address
City
State
Zip Code
Parent/Guardian Information
Full Name
Relationship to Participant
Phone Number
Email Address
Emergency Contact
Name
Phone Number
Relationship
Medical Information
Allergies or Medical Conditions
Medications Currently Taking
Physician Name and Phone
Consent and Authorization
I give permission for my child to participate in this program.
I authorize emergency medical treatment if necessary.
Parent/Guardian Signature
Date