Media Pass Parental Consent Form
Please complete this form to authorize your child’s participation and media coverage at the event.
Student Full Name
*
First Name
Last Name
Student Age
*
School/Organization Name
*
Grade/Class
*
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Student
*
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.
Event Name
*
Event Date
*
-
Month
-
Day
Year
Date
Event Location
*
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit Consent
Submit Consent
Should be Empty: