Consent Form & Emergency Contact Information
Today's Date
MM
/
DD
/
YYYY
Student Full Name
Your answer
Student Date of Birth
MM
/
DD
/
YYYY
Parent/Guardian Full Name
Your answer
Parent/Guardian Phone Number 1
Your answer
Parent/Guardian Phone Number 2
Your answer
Parent/Guardian Email
Your answer
Emergency Contact Full Name
Your answer
Emergency Contact Phone Number
Your answer
Emergency Contact Email
Your answer
Please indicate any serious medical conditions, allergies, physical limitations, learning disabilities, etc., that may affect you/your child’s participation in program activities:
Your answer
I acknowledge the Youth Programs is a department of Community Action Partnership of San Luis Obispo County, Inc., (CAPSLO) and that it sponsors a comprehensive range of programs; and I realize that NO MEDICAL INSURANCE IS PROVIDED. I, the adult client, and/or parent or guardian of the minor, hereby approve of participation for myself and/or my child in any or all of the following events and/or activities below. By checking the following boxes below, I agree to the following:
On behalf of my child, and/or minor, and/or myself, I hereby waive, release and discharge any and all claims for damages for death, personal injury, disability or property damage of any kind which may hereafter accrue to the child, minor or myself as a result of his/her/my participation in these programs.By my signature below, I hereby certify that I am the adult client, parent, or legal guardian of the minor and that I am acting in that capacity. Further, I acknowledge that I have read this document and understand its contents. *
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of Community Action Partnership of SLO Co..