Fill and Sign the Consent Parent 497331505 Form

Consent by Parent or Guardian for Minor to Spend Weekend with Adult not Related to Minor and Consent to Medical Care if Necessary Whereas, the undersigned _______________________ (Name of Parent or Guardian) , hereinafter called Parent , is the ________________ (parent or guardian) of ___________________ (Name of Minor) ; and Whereas, __________________ (Name of Minor) has requested permission to spend the weekend of __________________________________ (dates) with __________________ (Name of Adult) , who is a friend of the family; Now, therefore, the undersigned Parent agrees and consents as follows: _______________________ (Name of Minor) has my permission to spend the weekend of __________________________ (dates) with _____________________ (Name of Adult) , who resides at __________________________________________________________ ______________________ (street address, city, state, zip code) . ___________________ (Name of Minor) also has my permission and consent to go shopping with ________________ (Name of Adult) in __________________________________ (Name of City and State) during said weekend. In case of sickness or accident, ___________________ (Name of Adult) has my permission to secure medical treatment for __________________ (Name of Minor ) . The following information is being given in case of such sickness or accident requiring medical treatment:  Name of health insurance company covering _______________________ (Name of Minor ) :_____________________________________________________;  Policy Number: ___________________________________. I understand that if medical intervention is needed, every attempt will be made to contact the following person immediately:  Name of Parent: _______________________________________________;  Address: _____________________________________________________;  Phone number: ________________________________________________;  Name of alternate contact, if Parent cannot be reached: ________________ ___________________________________________;  Address of alternate contact: _____________________________________;  Phone number of alternate contact: ________________________________;  _____________________ (Name of Minor ) ’s medical considerations and medications: _____________ _________________________________________________________ ______________________________________________________________________ I assume all risk undertaken by my child ___________________ (Name of Minor) in participating in this weekend trip. I release ____________________ (Name of Adult) from any and all claims, loss, cost, damage or expense arising out of or from any accident or other occurrence that causes injury to the person or property of _____________________ (Name of Minor ) , during this weekend trip. Witness my signature this the ____________________ (date) . _______________________________ (P rinted Name of Parent) _______________________________ (Signature of Parent)