PARENTAL CONSENT FORM

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Name of Parent

First Name

Last Name

Name of Child

First Name

Last Name

Name of Child

First Name

Last Name

Name of Child

First Name

Last Name

Email Address

Phone Number

Please list Hospital Insurance Company, Policy number, Effective dates, list any allergies your child may have and Emergency contact information below.

Please choose one of the following options

Date

MM

DD

YYYY