Please provide details about the activity, event, or service your child will be participating in.
Activity/Event Name:
Description of Activity/Event:
Purpose of Activity/Event:
Dates of Activity/Event:
Times of Activity/Event:
(Start and End)
Location(s) of Activity/Event:
Organizer/Contact Person:
Organizer's Contact Number:
Supervising Staff/Volunteers:
Full Name | Role | |
|---|---|---|
Required Equipment/Attire:
Please provide the following information about your child.
Child's Full Name:
Child's Date of Birth:
Child's Gender:
Any Allergies (Food, Medication, etc.)?
Any Pre-existing Medical Conditions?
Any Current Medications?
Any Dietary Restrictions or Preferences?
Any Physical Limitations or Special Needs?
Any Behavioral Considerations?
Child's Emergency Contact Person:
(other than parent/guardian)
Child's Emergency Contact Number:
Parent/Guardian Name(s):
Relationship to Child:
Primary Phone Number:
Secondary Phone Number:
Email Address:
Mailing Address:
Address Line 1:
Address Line 2:
Suburb/City:
State/Province:
Postal/Zip Code:
Country:
Preferred Method of Contact:
Are there any legal custody agreements or restrictions we should be aware of regarding your child?
Do you give permission for your child to be photographed or video-recorded during the activity for promotional or archival purposes?
Do you give permission for your child's name to be used in connection with any photographs or videos?
Do you authorize the supervising staff to administer basic first aid for minor injuries or illnesses?
In the event of a medical emergency, do you authorize the supervising staff to seek professional medical attention for your child, including transportation to a medical facility if necessary?
Do you consent to any necessary medical, surgical, or dental treatment, including anesthesia, as deemed appropriate by qualified medical personnel, if you cannot be reached in an emergency?
Are there any religious or cultural beliefs that may affect medical treatment for your child?
Is your child covered by medical insurance?
Do you understand that while staff will make every reasonable effort to contact you, delays may occur, and immediate medical attention may be required?
Do you acknowledge that you are responsible for any medical expenses incurred for your child's treatment?
Please read and understand the potential risks associated with the activity.
Yes | No | |
|---|---|---|
Have you read and understood the description of the activity/event? | ||
Do you understand that participation in this activity may involve inherent risks, including but not limited to, physical injury, illness, and property damage? | ||
Are you aware of any specific risks or hazards associated with this activity that have been communicated to you? | ||
Do you understand that while all reasonable precautions will be taken, the organizers cannot guarantee the absolute safety of your child? | ||
Do you agree to ensure your child adheres to all rules and instructions given by supervising staff? | ||
Do you agree to inform the organizers promptly of any changes to your child's medical information or contact details? | ||
Do you understand that disruptive or unsafe behavior by your child may result in their removal from the activity, and you will be responsible for their immediate pick-up? | ||
Do you understand that any damage to property caused by your child's negligence may be your financial responsibility? | ||
Do you release [Organization Name] and its staff, volunteers, and agents from any liability for injuries or damages arising from your child's participation in this activity, except in cases of gross negligence or willful misconduct? | ||
Have you had the opportunity to ask any questions regarding this activity and this consent form? |
By signing below, you acknowledge and agree to all the terms outlined in this consent form.
I, the undersigned parent/guardian, confirm that I have read and understood all sections of this consent form, including the details of the activity, participant information, medical consent, and inherent risks. I voluntarily give my permission for my child, [Child's Full Name], to participate in the [Activity/Event Name] and agree to all the terms and conditions outlined herein.
Form Template Insights
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Mandatory Questions Recommendation
Please remove this mandatory questions recommendation before publishing.
Here are the questions that can be considered mandatory or critically important, and why:
In summary, the "mandatory" questions are those without which the consent would not be considered informed or legally valid, or those that are absolutely critical for the immediate safety and well-being of the child in an emergency. The form you've developed is excellent because it includes almost all of these essential elements, making it a robust template for any organization.