Perk Church Youth Event Consent Form Student Name * First Name Last Name Date of Birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Allergies? * Yes No Parent/Guardian Name * First Name Last Name Parent/Guardian Phone * (###) ### #### Consent I hereby give permission to secure emergency medical treatment, including anesthesia for my student during Perk Church Youth activities, in the event that I cannot be reached. Date * MM DD YYYY Thank you for completing this form! We look forward to hanging out with your student at our next Perk Church event!
