PARENTAL/GUARDIAN CONSENT FORM PARTICIPATION: I

The National Y o u t h D i vi s i o n
Of the
National Association of Negro Business and
Professional Women’s Clubs, Inc.
PARENTAL/GUARDIAN CONSENT FORM
Complete one per youth: Form Available at: www.nanbpwc.org
Club
District
Title of Youth Activity/Event:
Youth member’s Last Name
Youth member’s First Name
Youth member’s Middle Name
Address
City
State
Zip
Telephone
E-Mail
Hair Color
Eye Color
Age
Date of Birth
Height
Parent/Guardian’s Name(s)
Emergency Day Phone
Weight
Address if different from above
Emergency Evening Phone
Alternate [Relative-Name & Phone]
Other:
Alternate [Close Friend Name & Phone]
PARTICIPATION: I hereby give the above named y out h member permission to participate in the above
named event and assume responsibility for transportation to and from the event e i t h e r by:  payment 
conveyance. Are there any restrictions that will limit your child’s participation?  No  Yes [List on back] I
and anyone entitled to act on my behalf, waive and release the NANBPWC, INC. ( district, local, subdivisions
thereof, their agents, employees, chaperones, representatives and successors) from all claims or liabilities of any
kind arising out or of my child/ward’s participation in this organization including those which arise out of
negligence of the above named club/district or carelessness of my child.
PUBLICITY: I give my consent for the above named club/district to use my child’s name, photograph, videotape,
digital recordings and any likeness in any legitimate media form and type publication, including annual reports,
newsletters, and website and grant to the above named club/district any and all rights to said use without
compensation.
MEDICAL: It is understood that this release is only valid if my child’s life or well- being is at stake, and authorities are
unable, or time does not permit contacting of me or my designee for permission prior to necessary treatment or
action. Should an accident or illness require medical attention from a physician or hospital, I hereby grant
permission for the above named club/district to obtain any medical treatment necessary for my child. I
understand that in the case of such emergency, however my child will be treated as best as possible until I or an
alternate designated person is contacted.
My child has the following physical problems, or allergies to drugs, etc.
My child is presently taking the following medications:
Name of medical insurance company
Address of insurance company
Name of policy-holder and insured
Telephone
Policy Number [ff group also name employer)
My signature on this document indicates that I have read, completed and agree with the above, and grant my permission for my child to participate with
the above named club/district in the activity described in this document.
I am the parent, one of the parents or guardian with whom the above child/ward resides and have legal custody.
Parent/Guardian Signature
Date
Date
(Notary)
County of
, State of
Commission Expires:
This statement must be notarized and sealed if the event takes place outside of the participant’s home state.
11/2012