KENTUCKY STATE UNIVERSITY
OFFICE OF HUMAN RESOURCES ACADEMIC SERVICES #241 | 400 EAST MAIN STREET FRANKFORT, KY 40601 | (502) 597-6667 KYSU.EDU
PARENT/GUARDIAN CONSENT, RELEASE AND WAIVER OF LIABILITY FORM
Parent/Guardian Information
Volunteers Under Age 18
Parent/Guardian Name: ___ Relationship to Volunteer: ___
Parent/Guardian Name
Relationship to Volunteer
Phone Number: ___ Email Address: ___
Phone Number
Email Address
Consent to Participate
□ I, the undersigned parent or legal guardian of the above-named volunteer, hereby give my consent for my child to participate in volunteer activities at Kentucky State University (KSU).
I, the undersigned parent or legal guardian of the above-named volunteer, hereby give my consent for my child to
Acknowledgment of Risk
□ I understand that volunteering may involve certain risks, including but not limited to physical injury or property damage. I freely and voluntarily assume all such risks on behalf of my child.
I understand that volunteering may involve certain risks, including but not limited to physical injury or property
Release of Liability
□ On behalf of my child, I hereby release, waive, and discharge Kentucky State University, its trustees, officers, employees, and agents from any and all liability, claims, demands, or causes of action arising from participation in volunteer activities, including claims arising from negligence.
On behalf of my child, I hereby release, waive, and discharge Kentucky State University, its trustees, officers
Medical Treatment Authorization
☐ In the event of an emergency, I authorize KSU personnel to secure medical treatment for my child as deemed necessary. I understand that I am responsible for any medical expenses incurred.
In the event of an emergency, I authorize KSU personnel to secure medical treatment for my child as deemed
Allergies or Medical Conditions (if any):
___
Allergies or Medical Conditions (if any [1]
Allergies or Medical Conditions (if any [2]
Allergies or Medical Conditions (if any [3]
Photography and Media Release
□ I grant Kentucky State University the right to take photographs, video recordings, or other media of my child during volunteer activities and to use such media for educational, promotional, or public relations purposes without compensation.
I grant Kentucky State University the right to take photographs, video recordings, or other media of my child during
Certification and Signature
I certify that I have read this form, understand its contents, and agree to be bound by its terms on behalf of my child.
Parent/Guardian Printed:
Parent/Guardian Printed
Parent/Guardian Signature: ___ Date: ___
Parent/Guardian Signature
Date
Revised: September 2025