1. Organizer and Activity
Organizer: [ORGANIZATION NAME], of [ADDRESS], phone [PHONE], email [EMAIL] (the "Organizer"). Activity: [NAME AND DESCRIPTION OF THE ACTIVITY, e.g. summer day camp, overnight science trip, under-12 soccer season] (the "Activity"). Dates and times: [DATES, TIMES]. Location(s): [LOCATION(S), INCLUDING ANY OFF-SITE VENUES]. Transportation: [NONE / BUS / VAN / PRIVATE CARS DRIVEN BY STAFF OR VOLUNTEERS / FLIGHT]. Supervising adult(s) in charge: [NAME(S), PHONE]. Cost: [AMOUNT, or FREE].
2. Child and Parent or Guardian
Child's full name: [CHILD NAME]. Date of birth: [DATE OF BIRTH]. Grade or age group: [GRADE / AGE]. Parent or legal guardian: [PARENT / GUARDIAN NAME], relationship to child: [MOTHER / FATHER / LEGAL GUARDIAN / OTHER]. Address: [ADDRESS]. Phone: [PHONE]. Email: [EMAIL]. The signer confirms that they are the child's parent or legal guardian and have the legal authority to give this consent. Any custody order or restriction the Organizer should know about: [DETAILS, or NONE].
3. Consent to Participate
I give permission for my child to take part in the Activity described in section 1, including the following activities: [LIST, e.g. swimming, hiking, team sports, use of tools, field trips]. My child [MAY / MAY NOT] take part in [SWIMMING / WATER ACTIVITIES / OTHER SPECIFIC ACTIVITY]. I understand that the Activity involves some risk of injury, that the Organizer has described the main activities and risks to me, and that I may ask questions at any time. I agree that my child will follow the Organizer's rules and the reasonable instructions of staff, and that a child whose behavior puts others at risk may be sent home at my expense after I am contacted.
4. Emergency Contacts
If the Organizer cannot reach me, please contact, in this order: (1) [NAME, RELATIONSHIP, PHONE]; (2) [NAME, RELATIONSHIP, PHONE]. I will tell the Organizer promptly if any phone number changes before or during the Activity.
5. Medical Information
Allergies (food, medication, insect, other) and reaction: [DETAILS, or NONE]. Medications my child takes, dose and timing: [DETAILS, or NONE]. My child [MAY / MAY NOT] carry and use their own [INHALER / EPINEPHRINE AUTO-INJECTOR / OTHER]. Medical conditions, disabilities, or needs staff should know about, including dietary needs: [DETAILS, or NONE]. Health insurance provider and policy number (optional): [PROVIDER, NUMBER]. Child's doctor (optional): [NAME, PHONE]. I agree to update this information before the Activity if anything changes. Medication will be given only as described in the Organizer's medication policy and any separate authorization it requires.
6. Emergency Medical Treatment Authorization
If my child is injured or becomes ill during the Activity and I cannot be reached promptly, I authorize the Organizer's staff to call emergency services, to arrange transportation to a hospital or clinic, and to seek such emergency medical care as a licensed medical provider considers necessary. I understand that staff will try to contact me, and then my emergency contacts, as soon as possible, and that the treating provider may have its own consent requirements. I agree to be responsible for the cost of any treatment, to the extent not covered by insurance. This authorization applies only during the Activity and does not authorize planned or non-emergency treatment.
7. Photo and Media Release (Optional)
Please choose one: [ ] I give permission for the Organizer to take and use photos and video of my child during the Activity in [NEWSLETTERS, WEBSITE, SOCIAL MEDIA, PRINTED MATERIALS], without payment. The Organizer will not publish my child's full name or contact details with an image [UNLESS I AGREE SEPARATELY]. [ ] I do not give permission. Choosing "I do not give permission" does not affect my child's participation. I may withdraw this permission in writing at any time for future uses.
8. Pickup and Release
My child may be released only to me or to the following people, who will show photo identification at pickup: [NAME, RELATIONSHIP, PHONE]; [NAME, RELATIONSHIP, PHONE]. My child [MAY / MAY NOT] leave on their own or walk home at the end of the day. Any change to this list must be made in writing (email is enough) before pickup. People not on this list will not be allowed to collect my child [except in an emergency confirmed with me by phone].
9. General
I confirm that the information in this form is true and complete to the best of my knowledge. This consent is valid for the Activity dates in section 1 [or: for the (SEASON / SCHOOL YEAR) ending (DATE)], and I may withdraw it in writing at any time. This form is not a release or waiver of liability; any release is in a separate document. The Organizer will keep this form confidential and use the information only to run the Activity safely and as required by law. I agree that this form may be signed electronically, and that an electronically signed copy has the same effect as the original.
10. Signatures
PARENT OR LEGAL GUARDIAN: [PARENT / GUARDIAN NAME] Signature: ____________________ Date: [DATE] SECOND PARENT OR GUARDIAN (if required by the Organizer or a custody order): [NAME] Signature: ____________________ Date: [DATE] RECEIVED FOR THE ORGANIZER: [STAFF NAME, TITLE] Signature: ____________________ Date: [DATE]