Free parental consent form template 06Free parental consent form template 06
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Parental Consent Form
Name___________________________________ Age____ Birth Date_______ Gender
_______
Address_________________________________ Phone (____)____________________
City__________________________ State____________ Zip code _________________
School_________________________________ Current Grade (or just
completed)________
Parent(s) cell phones ______________________
______________________

Relation to student: ___________

Relation to student: ___________

Parent Email address: ___________________________
TO WHOM IT MAY CONCERN:
The undersigned does hereby give permission for our
(my) child,
________________________________________, to attend and participate in all
activities
(name of child)

sponsored by St. Timothy Youth Ministry from the time Jan. 1, 2015 through Dec.
31. 2015.
- We (I) authorize an adult, in whose care the minor has been entrusted,
to consent to any X-ray examination, anesthetic, medical, surgical, or
dental diagnosis or treatment, and hospital care, to