After-School Program Parent/Guardian Consent Form

Student Information

Full Name Date of Birth Grade School Name

Parent/Guardian Information

Full Name Relationship to Student Primary Phone Number Email Address

Emergency Contact

Contact Name Relationship Phone Number

Medical Information

Allergies or Medical Conditions Medications

Program Consent

I consent to my child's participation in the After-School Program.

Media Release

I give permission for photos/videos of my child to be used for program purposes.

Additional Comments

Parent/Guardian Signature

Name Date