Form 11009 (cha Sleepover at the National Archives Consent and Release C

SLEEPOVER AT THE NATIONAL ARCHIVES CONSENT AND RELEASE CHAPERONES ONLY
Please fill out the following only if the minor will be accompanied
by an adult who is not his/her parent or legal guardian:
I, the parent or legal guardian for the minor listed below, has approved for the Chaperone listed below to take my
child who is under the age of 18 to the Sleepover at the National Archives:
Minor’s Name (please print): ________________________________________ Age: ________________

Name: ________________________________________
Parent or Legal Guardian (please print)

Date: ________________

Parent or Legal Guardian’s Signature: _________________________________________ D.O.B:______________

Address: __________________________ Phone: _____________ Cell: ____________

City: _____________________________ State: ____________ Zip: _______________

I, the Chaperone, acknowledge that I have read and voluntarily sign this Consent Form and Release; that no oral
representations, statements or inducements apart from the foregoing written agreement have been made; and that I
am at least 18 years of age and have the legal capacity to enter into this agreement.

Chaperone’s Name (please print): ________________________________________
Chaperone’s Signature: _________________________________________ D.O.B:______________

Address: __________________________ Phone: _____________ Cell: ____________

City: _____________________________ State: ____________ Zip: _______________