Something To Chew On Teens Parental Consent Form
Please complete the form below.
Name of Event *
Your answer
Date of Event *
MM
/
DD
/
YYYY
Child's full name *
Your answer
Mother and Father's full names *
Your answer
Child's Age *
Your answer
Child's Birthday *
Your answer
Address (including state, city and zip) *
Your answer
Home Phone Number
Your answer
Parent Cell Phone Number *
Your answer
Child's Cell Phone Number *
Your answer
Name and number of emergency contact *
Your answer
Do you have hospital insurance? *
Name of child's physician *
Your answer
List any allergies (write none if there are none) *
Your answer
Medications being taken *
Your answer
Does your child have any special medical/health conditions? *
Please describe medical conditions indicated above
Your answer
Insurance Company and Policy Number *
Your answer
I hereby give permission for our/my child (named above) to attend and participate in activities sponsored by Something To Chew On Teens on the dates above. I hereby grant my consent for adult volunteers under whose auspices the program is conducted to secure all necessary emergency medical care and/or treatment that may be necessary for my child during the entire event including transportation, if provided by a volunteer. I release and hold harmless any said adult volunteer from any liability, who in good faith is placed in a position requiring decisions to be made for emergency care and treatment of the above named child. In case of accident, injury or loss, neither my family nor I will hold Something To Chew On nor any affiliate organization associated with the event, responsible or liable. In the event of an emergency, if you are unable to reach me at the above number, please contact the emergency contact listed above. *
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