Asian American Youth Council of Dayton

PARENTAL/GUARDIAN CONSENT FORM

A.  PARTICIPANT INFORMATION

Participant’s name: _____________________________________________________________________________

                                               Last                                                         Middle                                        First

Gender: (circle one)      Male   or   Female                         Date of Birth: _______/_______/_______                                   

Address:  _____________________________________________________________________________________

City: _______________________________________State: __________ Zip code: __________________________

School name: __________________________________________________________________________________

Phone number: (_______)__________-____________       Grade: (circle one)      9^th           10^th           11^th            12^th      

B.  PARENTAL/GUARDIAN INFORMATION

Name of parent or guardian: ______________________________________________________________________

                                                                            Last                                                                            First

Relationship: (check one)  __mother  __father  __grandmother __grandfather  __other, specify_________________

Address (if, different than above):  _________________________________________________________________

City: _________________________________________State: ____________ Zip code: ______________________

Home number: (______)_________-____________ Work number: (______)_________-_____________

C.      AUTHORIZATION

I, _____________________________ hereby grant permission for my child, ____________________ to participate

    (Name of parent/guardian)                                                                                               (Name of child)

in activities, meetings, or trainings sponsored by the Asian American Council, Dayton, Ohio (AAC) and the Asian American Youth Council of Dayton (AAYCD) projects that will take place at designated sites.  I believe that necessary precautions and plans for the care and supervision of my child during the duration of the planned activity will be taken.  Beyond this, I will not hold the Asian American Council staff responsible.

I agree that my child may appear in person or in voice, video or photographic presentation for radio, television, Internet (including YouTube.com) or print media reports and/or media campaign(s) resulting from participation in the above mentioned activities, and to complete confidential or anonymous surveys and participate in interviews for evaluation purposes.

We do not hold the Asian American Council or AAYCD staff responsible for any injuries incurred by my child while at or during transportation to and from these planned activities, and release and hold the AAC or AAYCD staff harmless for any damages or liabilities resulting from any injuries incurred by my child while being transported. 

(       ) I DO NOT wish for my child to be transported by the AAC/AAYCD staff. 

     _________________________________________________      _________________________

      Signature of Participant/Child                                                                                 Date    

     _________________________________________________      _________________________

     Signature of Parent/Guardian                                                                                    Date