Parental Consent Disclaimer Acknowledgement Form
Parental Consent Disclaimer Acknowledgement Form for parents or legal guardians to acknowledge and provide consent for a child’s participation in a non-medical activity or program.
Parent or Legal Guardian Full Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Legal Guardian
Other
Child's Full Name
*
First Name
Last Name
Activity or Program Name
*
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent or Guardian Email Address
*
example@example.com
Parent or Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Consent
Should be Empty: