Youth Club Consent Form

Participant Full Name

First NameLast Name

Date of Birth

Date

Age

Gender

School / Organization

Parent/Guardian Name

First NameMiddle NameLast Name

Relationship to Participant

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Emergency Contact Name

First NameMiddle NameLast Name

Emergency Contact Phone

Please enter a valid phone number.Format: (000) 000-0000.

Relationship

Does the participant have any medical conditions?

If yes, please describe

Allergies (if any)

Current medications

Activities participating in

Any special needs or requirements

Consent for photo/video use

Agree to club rules and code of conduct

Parent/Guardian Signature

Date