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.