Minor Independent Living Consent Form

Minor's Full Name

First NameMiddle NameLast Name

Date of Birth

Date

Age

Current Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Parent or Legal Guardian Full Name

First NameLast Name

Relationship to Minor

Contact Phone Number

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

Email Address

example@example.com

Approval Declaration

Proposed Living Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Start Date for Independent Living

Date

Type of Living Arrangement

Other

Reason for This Arrangement

Emergency Contact Name

First NameMiddle NameLast Name

Relationship to Minor

Emergency Contact Phone Number

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

Alternate Contact or Support Person Name

First NameMiddle NameLast Name

Relationship to Minor (Alternate)

Alternate Contact or Support Person Phone Number

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

I understand and agree to the independent living responsibilities

Other

Confirmation of responsibilities acknowledgment