Travel Consent Form – Mindset Kidz

Participant Information:

Name of Youth Participant: *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number: *

Email *

Birthdate:

Grade: *

Age at Time of Participation: *

Name of Activity/Event: *

Name of Group Sponsoring or Participating in this Event: *

Location of Event: *

Date(s) of Event: *

Time of Event: *

Parental Permission and Release of Liability:

I hereby give my son/daughter (named above) permission to participate in the event
listed. Although the event coordinator(s) will use the utmost precaution in guarding the
health of the above participant and preventing accidents, I release them from any liability in case of illness or injury as a result of this activity. Furthermore, I release the owner and driver of the car transporting my child to and from the event from any liability in case of illness or injury.

Guardian Name: *

First

Last

Guardian Phone Number: *

Guardian Email: *

Guardian Signature *

Clear Signature

Date *