{ "document_id": 16662, "page": 1, "width_pt": 612, "height_pt": 792, "rotation": 0, "pipeline_version": "paddleocr-vl-1.6+paul-48", "engine": "paddleocr_vl", "source_run_id": 16773, "item_count": 46, "counts_by_type": { "figure": 1, "form_field": 7, "header": 1, "heading": 7, "list": 3, "list_item": 13, "text": 13, "title": 1 }, "build_ms": 6, "items": [ { "id": "p1.1", "order": 1, "type": "figure", "bbox": { "l": 42.96, "t": 771.6, "r": 151.68, "b": 710.4 }, "text": "", "attrs": { "role": "page_header", "block_label": "header_image" } }, { "id": "p1.2", "order": 2, "type": "header", "bbox": { "l": 187.2, "t": 768.48, "r": 491.04, "b": 737.04 }, "text": "KENTUCKY STATE UNIVERSITY\nCooperative Extension Program 4-H Youth Development", "attrs": { "block_label": "header" }, "level": 2 }, { "id": "p1.3", "order": 3, "type": "title", "bbox": { "l": 219.6, "t": 725.28, "r": 458.16, "b": 710.4 }, "text": "TRANSPORTATION CONSENT FORM", "attrs": { "block_label": "doc_title" }, "level": 2 }, { 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"Date(s):___ County/Location: ___", "children": [ { "id": "p1.5.2.1", "order": 9, "type": "form_field", "bbox": { "l": 31.5046, "t": 658.7999, "r": 570.749, "b": 647.8049 }, "text": "", "attrs": { "field_kind": "text", "label": "Date(s):___ County/Location: ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p1.5.2" } } ] }, { "id": "p1.5.3", "order": 10, "type": "list_item", "bbox": { "l": 31.504635, "t": 640.049921, "r": 574.786145, "b": 629.054922 }, "text": "Employee Name: ___ Program Area: ___", "children": [ { "id": "p1.5.3.1", "order": 11, "type": "form_field", "bbox": { "l": 31.5046, "t": 640.0499, "r": 574.7862, "b": 629.0549 }, "text": "", "attrs": { "field_kind": "text", "label": "Employee Name: ___ Program Area: ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p1.5.3" } } ] } ] }, { "id": "p1.6", "order": 12, "type": "heading", "bbox": { "l": 24.96, "t": 609.84, "r": 144.24, "b": 597.84 }, "text": "Participant Information", 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"text", "label": "Parent/Guardian Name: ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p1.9" } } ] }, { "id": "p1.10", "order": 18, "type": "text", "bbox": { "l": 26.16, "t": 550.8, "r": 563.52, "b": 538.08 }, "text": "Email: ___", "children": [ { "id": "p1.10.1", "order": 19, "type": "form_field", "bbox": { "l": 26.9284, "t": 550.1287, "r": 561.5872, "b": 539.1337 }, "text": "", "attrs": { "field_kind": "text", "label": "Email: ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p1.10" } } ] }, { "id": "p1.11", "order": 20, "type": "text", "bbox": { "l": 24.24, "t": 550.56, "r": 283.2, "b": 538.56 }, "text": "Telephone:_____" }, { "id": "p1.12", "order": 21, "type": "heading", "bbox": { "l": 20.88, "t": 526.8, "r": 165.84, "b": 515.04 }, "text": "TRANSPORTATION CONSENT", "attrs": { "block_label": "paragraph_title" }, "level": 3 }, { "id": "p1.13", "order": 22, "type": "text", "bbox": { "l": 21.6, "t": 511.92, "r": 551.52, "b": 486.72 }, "text": "I give permission for my child to participate in all approved program activities, including educational, recreational, and supervised off-site activities and field trips associated with the program." }, { "id": "p1.14", "order": 23, "type": "text", "bbox": { "l": 19.92, "t": 474, "r": 569.76, "b": 448.32 }, "text": "I authorize my child to be transported by Kentucky State University employees, authorized volunteers, approved drivers, or contracted transportation providers, on university-approved vehicles for purposes related to camp activities." }, { "id": "p1.15", "order": 24, "type": "heading", "bbox": { "l": 19.68, "t": 432.72, "r": 349.68, "b": 420.24 }, "text": "ACKNOWLEDGEMENT OF TRANSPORTATION AND ACTIVITY RISKS", "attrs": { "block_label": "paragraph_title" }, "level": 3 }, { "id": "p1.16", "order": 25, "type": "text", "bbox": { "l": 19.44, "t": 415.2, "r": 556.32, "b": 390.48 }, "text": "I understand that participation in field trips and transportation to and from activities may involve certain inherent risks, including but not limited to:" }, { "id": "p1.17", "order": 26, "type": "list", "bbox": { "l": 27.84, "t": 388.8, "r": 218.16, "b": 327.36 }, "text": "", "attrs": { "item_count": 5 }, "children": [ { "id": "p1.17.1", "order": 27, "type": "list_item", "bbox": { "l": 28.08, "t": 388.8, "r": 105.12, "b": 378.24 }, "text": "vehicle travel," }, { "id": "p1.17.2", "order": 28, "type": "list_item", "bbox": { "l": 28.32, "t": 376.08, "r": 123.84, "b": 365.76 }, "text": "outdoor activities.", "marker": "•" }, { "id": "p1.17.3", "order": 29, "type": "list_item", "bbox": { "l": 28.08, "t": 363.12, "r": 141.6, "b": 352.56 }, "text": "recreational activities.", "marker": "•" }, { "id": "p1.17.4", "order": 30, "type": "list_item", "bbox": { "l": 28.08, "t": 350.4, "r": 115.92, "b": 339.84 }, "text": "public locations,", "marker": "•" }, { "id": "p1.17.5", "order": 31, "type": "list_item", "bbox": { "l": 27.84, "t": 338.16, "r": 218.16, "b": 327.36 }, "text": "and interaction with other participants.", "marker": "•" } ] }, { "id": "p1.18", "order": 32, "type": "text", "bbox": { "l": 19.44, "t": 326.4, "r": 541.92, "b": 300.72 }, "text": "I understand that Kentucky State University will take reasonable precautions to provide appropriate supervision and transportation procedures for participants." }, { "id": "p1.19", "order": 33, "type": "heading", "bbox": { "l": 20.4, "t": 282.48, "r": 174.48, "b": 270.48 }, "text": "EMERGENCY AUTHORIZATION", "attrs": { "block_label": "paragraph_title" }, "level": 3 }, { "id": "p1.20", "order": 34, "type": "text", "bbox": { "l": 19.2, "t": 267.84, "r": 587.28, "b": 229.44 }, "text": "In the event of illness, injury, accident, or emergency during transportation or off-campus activities, I authorize Kentucky State University staff and representatives to obtain emergency medical care for my child if I cannot be reached immediately. I understand that reasonable efforts will be made to contact me as soon as possible." }, { "id": "p1.21", "order": 35, "type": "heading", "bbox": { "l": 20.16, "t": 213.12, "r": 293.76, "b": 200.88 }, "text": "BEHAVIOR EXPECTATIONS DURING TRANSPORTATION", "attrs": { "block_label": "paragraph_title" }, "level": 3 }, { "id": "p1.22", "order": 36, "type": "text", "bbox": { "l": 19.92, "t": 196.8, "r": 233.52, "b": 185.28 }, "text": "I understand that participants are expected to:" }, { "id": "p1.23", "order": 37, "type": "list", "bbox": { "l": 20.4, "t": 182.64, "r": 516.96, "b": 118.56 }, "text": "", "attrs": { "item_count": 5 }, "children": [ { "id": "p1.23.1", "order": 38, "type": "list_item", "bbox": { "l": 27.84, "t": 182.64, "r": 239.76, "b": 171.36 }, "text": "follow all instructions from drivers and staff.", "marker": "•" }, { "id": "p1.23.2", "order": 39, "type": "list_item", "bbox": { "l": 28.08, "t": 169.2, "r": 178.08, "b": 158.4 }, "text": "remain seated when required,", "marker": "-" }, { "id": "p1.23.3", "order": 40, "type": "list_item", "bbox": { "l": 27.6, "t": 156.72, "r": 257.04, "b": 145.68 }, "text": "use appropriate behavior during transportation,", "marker": "-" }, { "id": "p1.23.4", "order": 41, "type": "list_item", "bbox": { "l": 27.36, "t": 143.76, "r": 383.04, "b": 132.96 }, "text": "and comply with all safety expectations and Code of Conduct requirements.", "marker": "•" }, { "id": "p1.23.5", "order": 42, "type": "list_item", "bbox": { "l": 20.4, "t": 131.04, "r": 516.96, "b": 118.56 }, "text": "Failure to follow transportation safety expectations may result in disciplinary action or removal from activities." } ] }, { "id": "p1.24", "order": 43, "type": "text", "bbox": { "l": 18.96, "t": 99.6, "r": 577.2, "b": 71.52 }, "text": "I certify that I am the parent/legal guardian of the participant listed; I have read and understand this transportation consent form; and I voluntarily grant permission for participation and transportation." }, { "id": "p1.25", "order": 44, "type": "text", "bbox": { "l": 21.12, "t": 52.56, "r": 553.92, "b": 40.56 }, "text": "Parent/Guardian Signature: ___ Date: ___", "children": [ { "id": "p1.25.1", "order": 45, "type": "form_field", "bbox": { "l": 22.5111, "t": 52.0914, "r": 551.4484, "b": 41.0963 }, "text": "", "attrs": { "field_kind": "text", "label": "Parent/Guardian Signature: ___ Date: ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p1.25" } } ] }, { "id": "p1.26", "order": 46, "type": "text", "bbox": { "l": 182.16, "t": 29.52, "r": 446.64, "b": 17.76 }, "text": "Kentucky State University is an equal opportunity provider." } ], "excluded_furniture": { "first": [], "last": [] } }