Parental Consent and Release Form

I, the undersigned 
Guardian First Name*Guardian Last Name*   ,
am the parent or legal guardian of the child/youth named
1st Child First Name*1st Child Last Name*   ,
who was BORN on   1st Child Date of Birth   
  
and RESIDES at
Street Address*Address Line 2*
City*State*
Zip*    .

For any situation, I assure that I will be available for the phone call at
Phone Number*  
and email 
Email*    .

Agreements:
Yes I agree that the organization's Personnel or Volunteers on behalf of the organization or other professional partnered with the organization has permission to use photographs for uses including but not limited to publicity, advertising and web content of my child and I understand no royalty or fee or other compensation will be payable to me.

Yes   I agree that the organization's Personnel or Volunteers on behalf of the organization or other professional partnered with the organization may interaction with my child.

Yes   I agree that the organization's Personnel or Volunteers on behalf of the organization or other professional partnered with the organization may observe, discuss, and retain information concerning my child for educational and scientific research purpose.

As a parent or legal guardian, I affirm that I have been completely informed all the activities that the child/youth will participate. I understand the general structure of the activities/programs and do not need to be informed of each and every activity.

Health History:
My child is currently have/had the following conditions/diseases:   
Conditions/Diseases   ,

and have these allergies:
Insect StingPollenNut      Poison Ivy, OakSoy  Wheat,   Other Allergies  

I hereby voluntarily release, forever discharge the community, the corporation, its officers, directors, employees, volunteers and agents from any and all claims, demands, or causes of action, which are connected with my child's participation in the programs or the use of the equipment and facilities. I agree to pay for any and all medical expenses incurred and give permission to the doctor or health care professional to provide medical care if necessary.

The information I've given in this form is complete and accurate.

By signing this form on Date*  ,
I confirm that I have fully informed myself of the contents of this Parental Consent and Release Form by reading it before I signed it.

I warrant that I possess all the rights, powers, and privileges of a parent or legal guardian necessary to execute this document with binding legal effect.
Signature*  
Guardian First Name   Guardian Last Name    

Additional Children
Additional Children must reside at the same address listed above under the same parental guardian.

I am also the parent or legal guardian of the child/youth named
2nd Child First Name  2nd Child Last Name 
who was born on    2nd Child Date of Birth   

3rd Child First Name   3rd Child Last Name 
who was born on 3rd Child Date of Birth   

4th Child First Name   4th Child Last Name 
who was born on 4th Child Date of Birth        Chickenpox   Measles   Mumps   Asthma   Sinusitis   Bronchitis   Diabetes   Heart Trouble   None      p>