Parental Consent and Release YTF 2025

Parental Consent and Release Form

Youth Services
As a parent or legal guardian, I affirm that I have been completely informed that my child/youth will participate in the Youth Services events inlcuding SMTX Youth Task Force. I understand the general structure of the Youth Task Force, which includes the following: monthly meetings, volunteer activities/programs, conferences and participating in other civic engagement programs sponsored by Community Action, Inc. of Central Texas. Youth Services, Community Action, Inc. of Central Texas and the San Marcos Youth Task Force work with several community partners and nonprofits that support Teen Programming.
Youth's Full Name

First NameMiddle NameLast Name
Youth's Date of Birth

MonthDayYear
Date
Youth Lives With

Other
Youth's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Admission

MonthDayYear
Date
Name of Parent/Guardian

First NameLast Name
Name of Parent/Guardian

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Permission to Release

I authorize the youth services program to release my child to leave the youth services event or program with the following persons. List name and telephone number for each person added to the pickup list. Children will only be released to a parent/guardian or to any of the persons listed below who have been designated by the parent/guardian after verification of identification.
Authorization for Emergency Medical Attention
I agree to pay for any and all medical expenses incurred and give permission to the doctor or health care professional to provide medical care if necessary. In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:
Parent/Guardian Signature
List any special needs that your child may have, such as food intolerance, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, and any other information which caregivers should be aware of:
Does your child have diagnosed allergies?
If yes, what allergies
List all medications your child takes on a regular basis (over the counter & prescription).
Print Parent/Guardian Name
Parent/Guardian Signature
Date

MonthDayYear
Date
Print Staff Name
Staff Signature
Date

MonthDayYear
Date
Should be Empty:

Parental Consent and Release Form