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Consent Forms
For Dream Tree Academy 573
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* Indicates required question
Email
*
Your email
Contact Information
Parent/Guardian Name: (First, Last)
*
Your answer
Address: (123 Normal Ln, Columbia, MO 65202)
*
Your answer
E-mail: (
name@example.com
)
*
Your answer
Cell: [(573)123-4567]
*
Your answer
Child's Name: (First, Last)
*
Your answer
Date of birth: (01/02/2009)
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MM
/
DD
/
YYYY
Age: (11 - 18 )
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Your answer
Gender
*
Your answer
Which ethnic group do you consider yourself to belong to?
*
Asian
Black
Mixed
White
Other
Prefer not to say
Required
Emergency Contact Details:
Who do we contact when we cannot reach you?
Name: (First, Last)
*
Your answer
Relationship:
*
Your answer
Phone No: (Home, Cell, Work)
*
Your answer
Emergency Medical Information:
Medical treatment information:
Doctor's Name (First, Last)
*
Your answer
Doctor's Address:
*
Your answer
Doctor's Telephone No:
*
Your answer
Preferred Hospital:
*
Your answer
Last Tetanus Shot:
*
Your answer
Does your child suffer from any condition requiring medical treatment including medication? Allergic reactions (medications, foods, plants, insects, etc.) If yes, please specify.
*
Your answer
I give permission for my child to take part in the activities provided by Dream Tree Academy 573 and for the information to be held and used by the Dream Tree Academy 573. I understand that Dream Tree Academy 573 cannot take responsibility if your child does not abide within the Rules.
*
I agree
I disagree
Required
I give permission for Dream Tree Academy 573 to use photo/video footage taken during the activities for promotional purposes such as displays / DVD presentations of our work. I understand that Dream Tree Academy 573 cannot take responsibility if your child does not abide within the Rules.
*
I agree
I disagree
Required
I give permission for medical attention to be sought in case of emergency. I understand that Dream Tree Academy 573 cannot take responsibility if your child does not abide within the Rules.
*
I agree
I disagree
Required
Dated: (01/02/2021)
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MM
/
DD
/
YYYY
Signature of parent or legal guardian: (First, Last)
*
Your answer
Relationship: (Father, Mother, Guardian...)
*
Your answer
Full Name: (First, MI, Last)
*
Your answer
Please complete for each child and send back.
Helps us maintain our records. We appreciate your time and understanding.
For further information call Raymond Hall or Karmella Wright at (573) 777-0781 or email:
dreamtreeacademy573@gmail.com
Columbia, MO 65202.
www.DreamTreeAcademy.com
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