Parent/Guardian Consent Form
Student's Name
*
First Name
Last Name
Student's Phone
Leave blank if no number
Format: (000) 000-0000.
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Activity
Activity Date
-
Month
-
Day
Year
Date
Activity Sponsor
Bible Drill
Beux & Debs
Children's Ministry
Mount Hebron Student Ministries (Youth)
Other
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Does your student have allergies or illnesses?
*
Yes
No
List all allergies and/or illnesses
*
n/a
Medications
*
n/a
Dosage/Time
*
n/a
Student has permission to take aspirin
*
Yes
No
Student has permission to take non-prescription medication for nausea
*
Yes
No
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Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
Parent/Guardian Phone
*
Format: (000) 000-0000.
Add a different/additional emergency contact person
Emergency Contact
First Name
Last Name
Emergency Contact Email
Emergency Contact Phone
Format: (000) 000-0000.
Signature
Submit
Should be Empty: