External Provider Parental Consent Example Form

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[Any] Provision
Parental Consent – External Provider
Proposed Date for the Activity: _______________________ _
Provider: ___________________________________________
Venue: _____________________________________________
Name of child:
Date of Birth:
Any Medical, Allergy or
Special needs?
Proposed date of
activity
Name:
Activity Leader
Contact number:
Venue for Activity and
details of activity being
undertaken
Transport
arrangements:
Arrangements for
Collection from Activity
Parent/Carer
Emergency Contact
number
I hereby given my consent to my child attending the above activity
Signed___________________________________________________
Date ____________
Please print name: _______________________________________________
This is a sample document and should be used for reference and adapted for your provision

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