Free parental consent form template 21Free parental consent form template 21
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Desart Hall
New Street
Kilkenny
Tel: (056) 7761200

Parental Consent Form
Club: ____________________
Date:________________
Volunteer Contact: ………………………….
Mobile No:……………………………………

Parent/Guardian Consent Form
Name of Participant: …………………………………………………………………
Parent/Guardian:

…………………………………………………………………

Address:

…………………………………………………………………

Date of Birth:

…………………… Age: ……………………………………

Home Tel No:

………………….

Mobile Tel No:…………………………

Third Party Emergency Contact Details ………………………………………………
Medical Information
Please tick as appropriate
My child has had TETANUS Vaccine/Booster
My child is allergic to PENICILLIN
My child is allergic to OTHER KNOWN MEDICATION
My child is allergic to certain FOODS
Does your child suffer from any MEDICAL CONDITION
Is your child currently using MEDICATION.
Do you suffer from Travel Sickness

Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No

If you answered YES to any of the above questions, please provide any additional
information about your child that is impo