Youth Activities Consent Form

Today's Date

MM

DD

YYYY

Primary Parent or Guardian

First Name

Last Name

Primary Phone

(###)

###

####

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent or Guardian Alternate

First Name

Last Name

Alternate Phone

(###)

###

####

Alternate Email

Child 1

First Name

Last Name

Age

Date of Birth

MM

DD

YYYY

Child 2

First Name

Last Name

Age

Date of Birth

MM

DD

YYYY

Child 3

First Name

Last Name

Age

Date of Birth

MM

DD

YYYY

Child 4

First Name

Last Name

Age

Date of Birth

MM

DD

YYYY

Allergies or medical concerns

Medications

Medical Insurance Carrier and Policy #

My child(ren) have permission

To attend events

To be photographed

By submitting this form, I authorize the church advisors to obtain medical treatment for my son/daughter in the event of a medical emergency, and I can not be reached.

Youth Activities Consent Form

507-289-4581

974 Skyline Drive SW

Rochester, MN 55902