Minor Checklist Form
Please complete this checklist to verify all required items for the minor have been addressed.
Minor's Full Name
*
First Name
Last Name
Minor's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Minor's Gender
*
Male
Female
Other
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Checklist of Required Items for the Minor
*
Rows
Completed
Permission Slip Turned In
1
Medical Information Provided
2
Emergency Contact Listed
3
Required Supplies Brought
4
Attendance Confirmed
5
Special Instructions Reviewed
6
Are there any allergies or medical conditions to note?
*
No
Yes (please specify below)
If yes, please provide details:
Additional Comments or Notes
Date of Checklist Completion
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Responsible Adult (Parent/Guardian/Staff)
*
Submit Checklist
Submit Checklist
Should be Empty: