Overnight Stay Guardianship Consent Form

Child's Information

Full Name: Date of Birth:

Parent/Guardian Information

Full Name: Phone Number: Address:

Overnight Stay Details

Name of Responsible Adult (Host): Host's Address: Host's Phone Number: Date(s) of Overnight Stay:

Emergency Contact Information

Contact Name: Relationship to Child: Phone Number:

Medical Information

Relevant Medical Information (Allergies, Medications, etc.):

Consent Statement

Consent Statement: