Special Needs Group Outing Consent Form
Participant Information
Name of Participant:
Date of Birth:
Parent/Guardian Name:
Contact Number:
Address:
Outing Details
Outing/Event Name:
Date of Outing:
Location:
Medical Information
Medical Conditions/Allergies:
Medications Required:
Emergency Contact Name & Number:
Consent
I give permission for my child/dependent to participate in the outing described above.
I authorize staff to seek medical assistance in case of emergency.
Date:
Signature of Parent/Guardian:
This form is for the exclusive use of the Special Needs Group Event described above.