Template For Parental Consent Form (If Under 18 Years Old)
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2Template for Parental Consent Form (if under 18 years old)
(Please feel to adapt to your individual affiliated JHU program)
Dear Parent or Guardian:
In order for your child to participate in a Johns Hopkins University affiliated program, we need your
consent and involvement in helping your child have a productive and safe experience. Please carefully
read and sign this parental consent form. If you have any questions or would like further information,
please call JHU SOURCE at (410) 955-3880 or email source@jhsph.edu.
Name of child: ________________________________________ Birth Date: _____________________
Address: ____________________________________________________________________________
City/State _____________________________________________ Zip Code _____________________
School _______________________________________________ Grade ________________________
Student's Telephone No. _______________________________________________________________
Physician's Name: ___________________________________________________________________
Physician's Telephone No. _____________________________________________________________
Physician's Address: __________________________________________________________________
PERSON TO BE NOTIFIED IN CASE OF AN EMERGENCY:
Name___________________________________________________________________________
Relationship to Child_____________ _________________________________________________
Phone: Home___________________________ Work ____________________________________
In connection with and consideration of my child's (named above) participation in the ________ and
related activities, I, on behalf of my child and myself, my heir(s), personal representative(s) and assign(s),
hereby represent and agree as follows:
•
I understand that my child will be a participant in a JHU affiliated program and related activities, and
I hereby give permission for him/her to serve in that capacity at JHU.
•
I understand that my child will be provided with the orientation and training necessary, and as
needed, for the safe and responsible performance of the duties assigned. He/she will be expected to
meet all the requirements of the position, including regular attendance and adherence to JHU,
hospital, and department policies and procedures.
•
Should my child require emergency medical treatment, first aid, or transportation to a hospital or
medical facility as a result of illness or injury associated with my child's participation in the JHU
program or related activities, I consent to any such treatment, first aid and/or transportation that may
be provided to my child, and understand that JHU will not be responsible for any costs associated
with any of the foregoing.
•
I authorize the release of educational recommendations from my child's school to the JHU SOURCE
office.
•
I understand that as a member of this JHU affiliated program and related activities, my child may
participate in physical activity. I represent and warrant that my child is in good physical condition,
and has no physical, health related or other problems which would preclude or restrict his/her
participation in this program or related activities or otherwise render his/her participation dangerous
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