CONSENT FORM

(Concern Form)

1. Child & Parent/Guardian Information

InformationDetails
Child's Full Name
Child's Gender
Child's Date of Birth
Child's Age
Home Address
Full Name of Parent/Guardian

2. Consent Statement

I hereby declare that:

  • ☐I permit and agree that my photo may be used for program purposes at the Wana Banyu Bening Foundation.
  • ☐I permit and agree that my video recordings may be used for program purposes at the Wana Banyu Bening Foundation.
  • ☐I permit and agree that voice recordings and text of what I say may be used for program purposes at the Wana Banyu Bening Foundation.
Place:
Date:

Signature of the child concerned:

Signature of parent/guardian: