Youth Impact Permission & Consent Form
Complete the required participant and guardian details, review the media and liability permissions, and sign where indicated.
Participant Information
Participant Full Name
*
First Name
Last Name
Participant Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Participant Phone Number (if applicable)
Please enter a valid phone number.
Format: (000) 000-0000.
Participant Email Address (if applicable)
example@example.com
Parent/Guardian Information
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Participant
*
Please Select
Mother
Father
Legal Guardian
Other
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Information
Does the participant have any allergies?
*
No
Yes (please specify below)
If yes, please list all allergies.
Does the participant have any medical conditions or take medications?
*
No
Yes (please specify below)
If yes, please describe medical conditions and list medications.
Photo/Video/Media Release
I grant permission for Clear Vision Youth Impact to use photos, videos, or other media of the participant for promotional or educational purposes.
*
I agree
I do not agree
Liability Waiver & Permissions
Waiver of Liability:
I acknowledge that participation in Clear Vision Youth Impact activities involves inherent risks. I hereby waive, release, and hold harmless Clear Vision, its staff, volunteers, and affiliates from any and all liability, claims, or demands arising from participation, except in cases of gross negligence or willful misconduct.
I have read, understand, and agree to the waiver of liability above.
*
I acknowledge and agree
Medical Treatment Permission:
In the event of an emergency, I authorize Clear Vision Youth Impact staff to seek medical attention for my child if I cannot be reached.
I give permission for emergency medical treatment as described above.
*
I give permission
Transportation Permission:
I give permission for my child to be transported by Clear Vision Youth Impact for official activities and events.
I give permission for transportation as described above.
*
I give permission
Signatures & Acknowledgement
Parent/Guardian Signature
*
Date (Parent/Guardian Signature)
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Participant Signature (required if participant is age 13 or older)
Date (Participant Signature)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent Form
Submit Consent Form
Should be Empty: