Legal Parental Consent Form

LEGAL PARENTAL CONSENT FORM

Parent/Guardian Name:   Address:

Minor Name:   Date of Birth:

Authorized Adult Name:   Relationship to Minor:

RECITALS

WHEREAS, Parent/Guardian named above is the lawful parent and/or legal guardian of the minor child named above and has the legal authority to provide the consents set forth in this agreement; and

WHEREAS, the Parent/Guardian desires to grant the Authorized Adult temporary authority to act on behalf of the minor for specified purposes, including travel and medical decision-making, subject to the terms and limitations set forth herein; and

WHEREAS, the Authorized Adult is willing to accept such responsibilities and act in the best interest of the minor in accordance with this Consent.

NOW THEREFORE, in consideration of the mutual covenants and promises contained herein, the parties agree as follows:

1. CONSENT AND AUTHORITY

Parent/Guardian hereby authorizes and empowers the Authorized Adult to act as temporary custodian and agent for the minor for the period specified in Section 6. Such authority includes, without limitation, the authority to make decisions regarding the minor's care, transportation, enrollment in programs, and to provide or consent to medical treatment as set forth in this document. This authorization is limited to the specific consents checked below and any additional written limitations stated herein.

2. SCOPE OF CONSENT

The Parent/Guardian elects the following consents (check all that apply):

Consent for domestic travel with the minor
Consent to authorize emergency and non-emergency medical, dental and surgical treatment for the minor
Consent to enroll the minor in educational, athletic, or recreational programs and to receive school-related information
Consent to permit photographs and video for routine identification or program purposes
Other:

3. MEDICAL AUTHORIZATION

If medical treatment is necessary, Parent/Guardian authorizes the Authorized Adult to consent to all medical, dental or surgical treatment, hospitalization and anesthesia on behalf of the minor. The Authorized Adult is authorized to sign any documents required by medical providers to obtain treatment. Parent/Guardian agrees to provide accurate and complete medical history below and to reimburse reasonable expenses incurred by the Authorized Adult in obtaining such treatment.

4. TRAVEL DETAILS

Purpose of travel or activity:

Anticipated departure date:   Anticipated return date:

5. REPRESENTATIONS AND WARRANTIES

Parent/Guardian represents and warrants that (a) they are the lawful parent or legal guardian of the minor and have the full right and authority to execute this Consent; (b) there are no court orders, custody agreements, or other legal restrictions prohibiting or limiting the Parent/Guardian's ability to grant this consent; and (c) all information provided in this form is true and complete to the best of the Parent/Guardian's knowledge.

6. INDEMNIFICATION

Parent/Guardian agrees to indemnify, defend and hold harmless the Authorized Adult from and against any and all claims, liabilities, losses, damages and expenses (including reasonable attorney fees) arising out of or related to actions taken by the Authorized Adult in good faith reliance on this Consent, except to the extent such claims arise from the Authorized Adult's willful misconduct or gross negligence.

7. DURATION AND REVOCATION

This Consent is effective for the period specified in Section 4 unless earlier revoked in writing by Parent/Guardian. Revocation shall not affect actions taken by the Authorized Adult prior to the Authorized Adult's receipt of written notice of revocation.

8. NOTICES

Any notice or communication required or permitted under this Consent shall be in writing and delivered to the addresses set forth in this form or to other addresses provided in writing by the parties. Notices shall be deemed given when personally delivered or sent by certified mail, return receipt requested.

9. GOVERNING LAW

This Consent shall be governed by and construed in accordance with the laws of the state of: without regard to principles of conflicts of law.

10. ENTIRE AGREEMENT; SEVERABILITY

This Consent constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior or contemporaneous understandings, agreements, or representations. If any provision of this Consent is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

11. AMENDMENT; WAIVER; COUNTERPARTS

This Consent may be amended or modified only by a subsequent written instrument signed by both parties. No failure or delay in exercising any right will operate as a waiver. This Consent may be executed in counterparts, each of which constitutes an original and all of which together constitute one instrument.

12. EMERGENCY CONTACT

CERTIFICATION AND ACKNOWLEDGMENT

By signing below, Parent/Guardian certifies under penalty of perjury that they are the natural or legal guardian of the minor, that the information provided herein is true and correct, and that they knowingly and voluntarily grant the authorities described in this Consent to the Authorized Adult for the period specified. Parent/Guardian acknowledges receipt of a fully executed copy of this Consent.

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