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PARENT/GUARDIAN AUTHORIZATION AND RELEASE

TO BE COMPLETED BY PROGRAM STAFF:

Program/Event Name: ___

Date(s):___

County/Location: ___

Employee Name: ___ Program Area: ___

Participant Information

Participant Name: ___

Date of Birth: ___

Parent/Guardian Name: ___

Phone Number: ___

Email: ___

PHOTO AND MEDIA RELEASE

I hereby authorize Kentucky State University and its representatives to photograph, video record, and/or otherwise capture the likeness of my child for use in educational, promotional, and program-related materials, including print and digital formats.

• I understand that:
• Participation is voluntary
• No compensation will be provided
• These materials may be used by Kentucky State University without restriction

□ I GIVE permission

□ I DO NOT GIVE permission

Parent/Guardian Initials: ___

FIELD TRIP (OFFSITE TRAVEL) AUTHORIZATION

I give permission for my child to participate in all scheduled camp activities, including supervised field trips both on and off campus, and to travel with authorized program staff.

□ I GIVE permission

□ I DO NOT GIVE permission

Parent/Guardian Initials: ___

PARTICIPANTNAME:___

MEDICATION ADMINISTRATION AUTHORIZATION

I authorize designated camp staff to administer prescription and/or over-the-counter medications to my child as documented on the Medication Administration Form.

• I understand that:
• Medications must be provided in original containers
• Instructions must be clearly labeled
• Medication will be administered by authorized personnel only

□ I GIVE permission

□ I DO NOT GIVE permission

Parent/Guardian Initials: ___

EMERGENCY MEDICAL TREATMENT AUTHORIZATION

I authorize Kentucky State University staff and representatives to seek and obtain medical care for my child in the event of illness or injury when I cannot be reached.

• This includes authorization for:
• Emergency medical treatment
• Hospitalization
• Necessary medical procedures as determined by licensed medical personnel I understand that I am financially responsible for any medical services provided.

□ I GIVE permission

□ I DO NOT GIVE permission

Parent/Guardian Initials: ___

HEALTH INSURANCE ACKNOWLEDGEMENT

• I understand that Kentucky State University does not provide medical insurance coverage for participants. I agree that:
• I am responsible for all medical expenses incurred
• I have provided current insurance information (if applicable)

□ I ACKNOWLEDGE AND AGREE

Parent/Guardian Initials: ___

PARTICIPANTNAME:___

GENERAL PROGRAM ACKNOWLEDGEMENT

• I acknowledge that:
• My child is expected to follow all camp rules, policies, and the Code of Conduct
• Failure to comply may result in disciplinary action, including dismissal from the program
• I have reviewed the program expectations with my child

□ I ACKNOWLEDGE AND AGREE

Parent/Guardian Initials: ___

UNIVERSITY POLICY ACKNOWLEDGEMENT

• I acknowledge that:
• My child is expected to follow all camp rules, policies, and the Code of Conduct
• Failure to comply may result in disciplinary action, including dismissal from the program
• I have reviewed the program expectations with my child

□ I ACKNOWLEDGE AND AGREE

Parent/Guardian Initials: ___

SIGNATURES OF ACKNOWLEDGEMENT

I certify that I am the parent/legal guardian of the participant listed above and have the authority to grant these permissions. I have read and understand the information provided in this form.

Parent/Guardian Signature: ___

Printed Name: ___

Date: _____

Kentucky State University is an equal opportunity provider.