Activity Consent Form
Participant Name
First Name
Middle Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
1
Age
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Activity Name
From
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
To
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I, undersigned, agree with the following statements:
I am the participant or parent/guardian of the participant of the activity specified above.
I understand that participation in this activity involves the risk of personal injury, including death, due to the physical, mental, and emotional challenges in the activities offered.
I understand that participation of this activity is voluntary and I understand that it requires participants to follow instructions and abide by all applicable rules and the standards of conduct.
I am giving my consent in case of an emergency involving my child, and in the event I cannot be reached, medical provider can secure propertreatment, including hospitalization, anesthesia, surgery, or injections of medication for my child.Medical providers are authorized to disclose protected health information to the adult in charge and/or any physician or health care provider involved in providing medical care to the participant.
With appreciation of the dangers and risks associated with programs and activities includingpreparations for and transportation to and from the activity, on my own behalf and/or on behalf of mychild, I hereby fully and completely release and waive any and all claims for personal injury, death,or loss that may arise against the organization, the local council, the activity coordinators,and all employees, volunteers, related parties, or other organizations associated with any programor activity.
Parent/Guardian Name (If Applicable)
First Name
Last Name
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: