[ { "page": 1, "items": [ { "page": 1, "type": "TITLE", "location": { "l": 219.6, "t": 725.28, "r": 458.16, "b": 710.4 }, "text": "TRANSPORTATION CONSENT FORM", "reading_order": 0, "level": 1 }, { "page": 1, "type": "TITLE", "location": { "l": 29.04, "t": 695.52, "r": 198.48, "b": 684.72 }, "text": "TO BE COMPLETED BY PROGRAM STAFF:", "reading_order": 1, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 29.04, "t": 678, "r": 572.64, "b": 666 }, "text": "Program/Event Name: ___", "reading_order": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 31.92, "t": 659.28, "r": 571.68, "b": 647.28 }, "text": "Date(s):___ County/Location: ___", "reading_order": 3 }, { "page": 1, "type": "TEXT", "location": { "l": 31.2, "t": 641.04, "r": 576, "b": 628.56 }, "text": "Employee Name: ___ Program Area: ___", "reading_order": 4 }, { "page": 1, "type": "FIGURE", "location": { "l": 27.36, "t": 624, "r": 577.68, "b": 614.4 }, "text": "", "reading_order": 5 }, { "page": 1, "type": "TITLE", "location": { "l": 24.96, "t": 609.84, "r": 144.24, "b": 597.84 }, "text": "Participant Information", "reading_order": 6, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 23.28, "t": 593.52, "r": 385.92, "b": 581.52 }, "text": "Participant Name: Date of Birth:", "reading_order": 7 }, { "page": 1, "type": "TEXT", "location": { "l": 388.32, "t": 593.76, "r": 578.64, "b": 581.28 }, "text": "Date of Birth:", "reading_order": 8 }, { "page": 1, "type": "TEXT", "location": { "l": 25.2, "t": 572.16, "r": 422.64, "b": 560.4 }, "text": "Parent/Guardian Name: ___", "reading_order": 9 }, { "page": 1, "type": "TEXT", "location": { "l": 26.16, "t": 550.8, "r": 563.52, "b": 538.08 }, "text": "Email: ___", "reading_order": 10 }, { "page": 1, "type": "TEXT", "location": { "l": 24.24, "t": 550.56, "r": 283.2, "b": 538.56 }, "text": "Telephone:_____", "reading_order": 11 }, { "page": 1, "type": "TITLE", "location": { "l": 20.88, "t": 526.8, "r": 165.84, "b": 515.04 }, "text": "TRANSPORTATION CONSENT", "reading_order": 12, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "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.", "reading_order": 13 }, { "page": 1, "type": "TEXT", "location": { "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.", "reading_order": 14 }, { "page": 1, "type": "TITLE", "location": { "l": 19.68, "t": 432.72, "r": 349.68, "b": 420.24 }, "text": "ACKNOWLEDGEMENT OF TRANSPORTATION AND ACTIVITY RISKS", "reading_order": 15, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "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:", "reading_order": 16 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 28.08, "t": 388.8, "r": 105.12, "b": 378.24 }, "text": "vehicle travel,", "list_id": "L1", "level": 0, "reading_order": 17 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 28.32, "t": 376.08, "r": 123.84, "b": 365.76 }, "text": "outdoor activities.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 18 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 28.08, "t": 363.12, "r": 141.6, "b": 352.56 }, "text": "recreational activities.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 19 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 28.08, "t": 350.4, "r": 115.92, "b": 339.84 }, "text": "public locations,", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 20 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 27.84, "t": 338.16, "r": 218.16, "b": 327.36 }, "text": "and interaction with other participants.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 21 }, { "page": 1, "type": "LIST_ITEM", "location": { "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.", "list_id": "L1", "level": 0, "reading_order": 22 }, { "page": 1, "type": "TITLE", "location": { "l": 20.4, "t": 282.48, "r": 174.48, "b": 270.48 }, "text": "EMERGENCY AUTHORIZATION", "reading_order": 23, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "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.", "reading_order": 24 }, { "page": 1, "type": "TITLE", "location": { "l": 20.16, "t": 213.12, "r": 293.76, "b": 200.88 }, "text": "BEHAVIOR EXPECTATIONS DURING TRANSPORTATION", "reading_order": 25, "level": 2 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 19.92, "t": 196.8, "r": 233.52, "b": 185.28 }, "text": "I understand that participants are expected to:", "list_id": "L2", "level": 0, "items": [ { "page": 1, "type": "LIST_ITEM", "location": { "l": 27.84, "t": 182.64, "r": 239.76, "b": 171.36 }, "text": "follow all instructions from drivers and staff.", "marker": "•", "list_id": "L2", "level": 1, "reading_order": 0 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 28.08, "t": 169.2, "r": 178.08, "b": 158.4 }, "text": "remain seated when required,", "marker": "-", "list_id": "L2", "level": 1, "reading_order": 1 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 27.6, "t": 156.72, "r": 257.04, "b": 145.68 }, "text": "use appropriate behavior during transportation,", "marker": "-", "list_id": "L2", "level": 1, "reading_order": 2 }, { "page": 1, "type": "LIST_ITEM", "location": { "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": "•", "list_id": "L2", "level": 1, "reading_order": 3 } ], "reading_order": 26 }, { "page": 1, "type": "LIST_ITEM", "location": { "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.", "list_id": "L2", "level": 0, "reading_order": 27 }, { "page": 1, "type": "TEXT", "location": { "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.", "reading_order": 28 }, { "page": 1, "type": "TEXT", "location": { "l": 21.12, "t": 52.56, "r": 553.92, "b": 40.56 }, "text": "Parent/Guardian Signature: ___ Date: ___", "reading_order": 29 }, { "page": 1, "type": "TEXT", "location": { "l": 182.16, "t": 29.52, "r": 446.64, "b": 17.76 }, "text": "Kentucky State University is an equal opportunity provider.", "reading_order": 30 } ] } ]