Parental Consent Form For Internship

Parental Consent Form For Internship
Please complete this form to provide parent or guardian consent for a student’s internship placement.
Student Information
Student Full Name
First NameMiddle NameLast Name
Date of Birth
MonthDayYear
Date
Age
School Name
Grade/Class
Student Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent or Guardian Information
Parent or Guardian Full Name
First NameMiddle NameLast Name
Relationship to Student
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Internship Placement Details
Organization/Company Name
Department or Role
Internship Start Date
MonthDayYear
Date
Internship End Date
MonthDayYear
Date
Schedule or Hours
Supervisor/Contact Person Details
First NameMiddle NameLast Name
Emergency and Health Information
Emergency Contact Name
First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical, Allergy, or Special Instruction Notes
Parental Authorization and Acknowledgment
Parent or Guardian Signature
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