Child Health Study Parental Consent Form
Please complete this form to provide your consent for your child's participation in the health study. Your responses will remain confidential.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Gender
*
Male
Female
Other
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Legal Guardian
Other
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does your child have any allergies or medical conditions we should be aware of? Please specify.
By signing below, I confirm that I am the parent or legal guardian of the above-named child and that I consent to their participation in the child health study as described.
*
Submit Consent
Submit Consent
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