Carwood Cares Consent Form
Please complete this form and submit it along with an application for the program. We will be in touch with you soon!
Participant Full Name *
Your answer
Participant Birth Date *
Your answer
Parent/Guardian Name (if participant under 18) *
Your answer
Parent address *
Your answer
Parent primary phone number *
Your answer
Parent primary email address *
Your answer
Please list any participant medical conditions or allergies the program should be aware of (the program will not administer medications) *
Your answer
Please list any emergency contact (name & phone number & relationship to participant) other than contact already listed on this form. *
Your answer
By entering your name below and submitting this form, you are consenting to: 1) The participant listed on this form taking part in the Carwood Cares program as explained in the program description 2) The participant does not suffer from any medical conditions or allergies other than the ones list on this form 3) Should the participant require emergent medical attention during his/her participation in the program, program staff have permission to secure medical attention from the closest hospital, emergent provider or other licensed medical provider as needed. Should medical attention, not be emergent but be deemed necessary, program staff will seek parent/guardian permission prior to obtaining medical services. *
Your answer
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