Parent/Guardian Consent & Media Release

Parent/Guardian Full Name

First NameLast Name

Date

Relationship to Child

Mother, father, grandmother, etc.

Phone Number

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you give permission for your child to participate in all programs, workshops,and activities offered by Aunty House?

YesNo

Do you consent for your child to attend off-site activities such as community events, performances, shows, museums, outdoor trips, partner organization events, and other supervised outings?

YesNo

Please list any activities you do not want your child to participate in (if any):

Is your child currently involved in any extracurricular activities, clubs, sports, or programs? If yes, please list the organizations and schedules:

What days and times is your child generally available for Aunty House activities?

Has your child ever been involved with the juvenile justice system (arrests, probation, court involvement)? If yes, please provide context (optional but encouraged for proper support):

Has your child ever been suspended, expelled, or faced behavioral challenges in school? If yes, please explain:

Are there any emotional, behavioral, or safety concerns you would like us to be aware of?

Do you consent to basic first aid (bandages, ice packs, antiseptics) being administered to your child if needed?

YesNo

Do you consent for Aunty House staff to seek emergency medical treatment for your child if you cannot be reached?

YesNo

Please list any medical conditions, health concerns, or physical limitations we should be aware of:

Please list any allergies (food, medication, environmental):

Does your child require or carry emergency medication (EpiPen, inhaler, etc.)? If yes, please explain:

Emergency Contact #1

First NameLast Name

Relationship to You

Parent, Guardian, etc.

Phone Number

Please enter a valid phone number.

Emergency Contact #2

First NameLast Name

Relationship to You

Parent, Guardian, etc.

Phone Number

Please enter a valid phone number.

Do you grant permission for Aunty House to photograph, record, or film your child during activities, programs, and events?

YesNo

Do you consent to photos/videos being used for (Check all that apply):

If you selected “None,” please specify how you prefer your child to be represented(ex: no photos, face blurred, group photos only):

Behavior & Conduct Agreement:
I acknowledge that Aunty House is committed to maintaining a respectful, safe, and inclusive environment for all participants. I understand that if my child engages in behavior that endangers their own safety or the safety of others, Aunty House reserves the right, in its sole discretion, to suspend or discontinue my child’s participation in the program.

Medical & Emergency Authorization:
I hereby authorize Aunty House staff to administer basic first aid and to seek or obtain appropriate emergency medical care for my child in the event that I cannot be reached in a timely manner. I understand that this authorization is limited to emergency care deemed necessary for the health and safety of my child and does not constitute consent to elective or non-emergency medical procedures.

Accuracy Agreement:
I certify that all information provided in this form is true, complete, and accurate to the best of my knowledge. I understand that providing false, incomplete, or misleading information may affect my child’s eligibility for, or continued participation in, the program.

Acknowledgment & Consent
By signing below, I acknowledge that I have carefully read and fully understand the agreements and authorizations set forth in the above Sections. I voluntarily consent to and accept these terms as a condition of my child’s participation in the program.

Date

Parent Signature