I have read and understand the conditions of the Antoine Cooksey Foundation (ACF) Youth Programs as explained on the Antoine Cooksey Foundation website. I understand that this application will be available only to qualified people who need to see it in the course of their duties. I affirm that all of this application, is my own work for formally cited from other sources. I affirm the information contained herein is true and accurate to the best of my knowledge and belief. 

I, ___  ___  ___ the undersigned, being the parent/legal guardian of the youth named above, do hereby consent the participation of my youth in all the scheduled youth activities of Antoine Cooksey Foundation, and any other supervised customarily associated with its youth programs, including but not limited to the following (please initial each): 

Date: ___ 

Further, I certify that my youth is physically fit and able to participate in all recreational and sporting events. (where applicable)

______If I wish to revoke this consent for any reason, I will promptly notify Antoine Cooksey Foundation in writing.

Note to Parent: If giving consent for one activity only, or if this consent is otherwise restricted, please specify:

I understand that this consent form will be valid for 1 year from the date I sign it, unless I revoke my permission in writing to: 

Antoine Cooksey Foundation
Attn: ACF Administrator
P. O. Box 714
Minden, Louisiana 71058

I give permission for my youth to travel to outings with the Antoine Cooksey Foundation Youth Programs, in the facility vehicles, van/bus, rental vehicle, or sponsors personal vehicles.

Youth Section