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Parent/Carer Name*

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E-mail*

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Address*

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Phone number*

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Child's name*

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Child's date of birth*

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Your child on an IEP (Individualized Education Plan, Special Education, etc)?

We need to provide any extra help, for example, because of a disability, or are there any activities that your child cannot participate in?

Do we have your permission to take and use photos and videos of your child for marketing and publicity purposes in any form including social media?

Emergency Contact (if the parent cannot be reached)*

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Is there anything else we should know? Any allergy that we should be aware of?

Parent/Carer's Consent: I agree ~ My child taking part in the stated activity ~ Keeping a record of this form for health and safety reasons ~ Any medical treatment that my child may need to be give

For what activity/activities did you fill in the Consect Form?*

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Parent/Carer Consent Form

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