KENTUCKY STATE UNIVERSITY Cooperative Extension Program 4-H Youth Development PARENT/GUARDIAN AUTHORIZATION AND RELEASE Name of Program/Camp:___
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.