Hustlentrepeneur IRB Permission Slip Cohort

Hustlentrepeneur IRB Permission Slip Cohort

Permission slip and consent form for participation in the Hustlentrepeneur Youth Mentoring & Diversion Program.
Participant’s Name (Printed/Typed)

First NameLast Name
Date (Participant Certification)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Media Release Consent
Parent/Guardian Name

First NameLast Name
Participant Name

First NameLast Name
Parent/Guardian Signature
Date (Parent/Guardian Consent)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
State of Residence
Program or Facility Name
Printed Name of Affiliate Leader

First NameLast Name
Emergency Contact Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Youth Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Known Allergies/Conditions
Should be Empty: