Free parental consent form template 39Free parental consent form template 39
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Template for Parental Consent Form (if under 18 years old)
(Please feel to adapt to your individual affiliated JHUSOM program)
Dear Parent or Guardian:
In order for your child to participate in a Johns Hopkins University School of Medicine (JHUSOM)
affiliated program, we need your consent and involvement in helping your child have a productive and
safe experience. Please carefully read and sign this parental consent form. If you have any questions or
would like further information, please call Office for Student Diversity, Johns Hopkins University School
of Medicine at 410-614-8759.
Name of child: ________________________________________ Birth Date: _____________________
Address: ____________________________________________________________________________
City/State _____________________________________________ Zip Code _____________________
School _______________________________________________ Grade ________________________
Student's Telephone No. ____________________________________