Parental Consent Form Template

This Parental Consent Form (the “Form”) is completed by the undersigned parent/legal guardian as of [Date].

1. Minor Information

1.1 Minor Full Name. [Child’s full legal name].
1.2 Date of Birth. [DOB].
1.3 Home Address. [Address].
1.4 School/Organization (Optional). [Name].

2. Parent/Guardian Information

2.1 Parent/Guardian Name. [Full name].
2.2 Relationship to Minor. ☐ Parent ☐ Legal guardian ☐ Other: [Relationship].
2.3 Phone Number. [Phone].
2.4 Email Address. [Email].
2.5 Address (If Different). [Address].
2.6 Second Parent/Guardian (Optional). [Name/Phone/Email].

3. Activity or Service Details

3.1 Activity/Service Name. [Name].
3.2 Description. [Brief description].
3.3 Dates and Times. [Dates/times].
3.4 Location. [Address/location].
3.5 Supervising Organization/Provider. [Name].
3.6 Supervisor/Leader Contact (Optional). [Name/Phone].

4. Consent and Permissions

4.1 Participation Consent. I give permission for the Minor to participate in the activity/service described in Section 3.
4.2 Transportation Consent (Optional). ☐ Yes ☐ No. If yes: transportation method: [Bus/Carpool/Other].
4.3 Media Release (Optional).
☐ I consent to photos/video/audio recordings of the Minor for: ☐ Internal use ☐ Public promotional use
☐ I do not consent to photos/video/audio recordings
4.4 Off-Site Activities (Optional). ☐ Allowed ☐ Not allowed.

5. Emergency Contact and Medical Information

5.1 Emergency Contact Name. [Name].
5.2 Emergency Contact Phone. [Phone].
5.3 Allergies/Medical Conditions (Optional). [Details].
5.4 Medications (Optional). [Details].
5.5 Primary Physician (Optional). [Name/Phone].
5.6 Health Insurance (Optional). Provider: [Name], Policy #: [Number].

6. Emergency Medical Authorization (Optional)

6.1 Authorization. In the event of an emergency and if I cannot be reached, I authorize the supervising organization/provider to obtain emergency medical evaluation and treatment for the Minor, as recommended by a licensed medical provider.
6.2 Limitations. This authorization is limited to emergency care and does not include non-emergency procedures unless required to prevent serious harm.

7. Acknowledgments

7.1 Accuracy. I confirm the information provided is accurate to the best of my knowledge.
7.2 No Guarantee of Safety. I understand that participation may involve risks and that the supervising organization will take reasonable precautions, but cannot guarantee safety.
7.3 Revocation. I may revoke this consent in writing, but revocation may not affect activities already scheduled or underway.

Signatures

By signing below, the undersigned parent/legal guardian grants the permissions described in this Form.

Parent/Guardian Name: [Name]
Date: [Date]
Signature: ___________________________

Second Parent/Guardian (Optional): [Name]
Date: [Date]
Signature: ___________________________

Organization/Provider Representative (Optional): [Name]
Title/Role: [Title]
Date: [Date]
Signature: ___________________________