Parental Consent Form (Sample)

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Parental Consent Form (sample)
Name of Child:________________________________Date of Birth: ___________________
Race/Ethnic Origin:_______________Any Disability or Special Needs__________________
Event:
_____________________________________________________________
Date(s) of Event: ____________________________________________________________
Home Address of parent/carer: _________________________________________________
__________________________________________________________________________
__________________________________________ Post Code: _____________________
Tel. No. (Day): ________________________ (Evening): _______________________
Mobile No: _______________________________________
Medical Details:
Doctor’s Name: ________________________ NHS Card No:_________________________
Additional details: (any information, given in confidence, of which the organisers should be aware –
specific dietary requirements, details of any medication, allergies etc.)
_________________________________________________________________________
Declaration:
I have received comprehensive details of this event and consent to my child taking part in the
activities indicated. I consent to my child receiving any medical treatment, which, in the opinion of
a qualified medical practitioner, may be necessary.
Signed: _____________________________________ (Parent/Carer)
Signed: _____________________________________ (Child)
Date:
_____________________________________

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