Confirmation Retreat Parental Consent Form

Participant Information

Full Name

Date of Birth

Gender

Address

Phone Number

Parent/Guardian Information

Parent/Guardian Name

Phone Number

Medical Information

Allergies or medical conditions Medications currently taking Physician's Name & Phone Insurance Provider & Policy Number

Consent and Authorization

I, the undersigned parent/guardian, give permission for my child to attend the Confirmation Retreat. I authorize the adult supervisors to secure any necessary medical treatment in case of emergency.

Parent/Guardian Signature Date