Mosque Youth Program Consent Form
Participant Information
Full Name
Date of Birth
Address
Phone Number
Email
Parent/Guardian Information
Full Name
Relationship to Participant
Phone Number
Email
Medical Information
Allergies or Medical Conditions
Emergency Contact Name
Emergency Contact Phone
Consent and Agreement
I give permission for my child to participate in the Mosque Youth Program.
I authorize emergency medical treatment if necessary.
I consent to the use of photographs/videos of my child for program purposes.
Parent/Guardian Signature
Date