[ { "page": 1, "items": [ { "page": 1, "type": "TITLE", "location": { "l": 186.48, "t": 711.36, "r": 534.24, "b": 695.28 }, "text": "PARENT/GUARDIAN AUTHORIZATION AND RELEASE", "reading_order": 0, "level": 1 }, { "page": 1, "type": "TEXT", "location": { "l": 37.92, "t": 665.76, "r": 207.84, "b": 654.96 }, "text": "TO BE COMPLETED BY PROGRAM STAFF:", "reading_order": 1 }, { "page": 1, "type": "TEXT", "location": { "l": 37.68, "t": 648.96, "r": 582, "b": 636 }, "text": "Program/Event Name: ___", "reading_order": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 38.64, "t": 630, "r": 279.36, "b": 617.28 }, "text": "Date(s):___", "reading_order": 3 }, { "page": 1, "type": "TEXT", "location": { "l": 42.24, "t": 629.76, "r": 580.32, "b": 617.04 }, "text": "County/Location: ___", "reading_order": 4 }, { "page": 1, "type": "TEXT", "location": { "l": 40.32, "t": 611.28, "r": 584.4, "b": 598.56 }, "text": "Employee Name: ___ Program Area: ___", "reading_order": 5 }, { "page": 1, "type": "TITLE", "location": { "l": 38.64, "t": 579.84, "r": 177.12, "b": 565.68 }, "text": "Participant Information", "reading_order": 6, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 38.4, "t": 557.76, "r": 508.56, "b": 545.04 }, "text": "Participant Name: ___", "reading_order": 7 }, { "page": 1, "type": "TEXT", "location": { "l": 38.64, "t": 537.36, "r": 504.96, "b": 524.16 }, "text": "Date of Birth: ___", "reading_order": 8 }, { "page": 1, "type": "TEXT", "location": { "l": 38.4, "t": 516.72, "r": 507.6, "b": 503.04 }, "text": "Parent/Guardian Name: ___", "reading_order": 9 }, { "page": 1, "type": "TEXT", "location": { "l": 37.92, "t": 495.36, "r": 510, "b": 481.68 }, "text": "Phone Number: ___", "reading_order": 10 }, { "page": 1, "type": "TEXT", "location": { "l": 38.4, "t": 474.72, "r": 510.48, "b": 460.8 }, "text": "Email: ___", "reading_order": 11 }, { "page": 1, "type": "TITLE", "location": { "l": 44.88, "t": 432, "r": 215.76, "b": 418.32 }, "text": "PHOTO AND MEDIA 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541.44, "b": 146.4 }, "text": "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.", "reading_order": 19 }, { "page": 1, "type": "TEXT", "location": { "l": 45.12, "t": 126.72, "r": 144.48, "b": 114.24 }, "text": "□ I GIVE permission", "reading_order": 20 }, { "page": 1, "type": "TEXT", "location": { "l": 45.6, "t": 110.64, "r": 186.48, "b": 97.92 }, "text": "□ I DO NOT GIVE permission", "reading_order": 21 }, { "page": 1, "type": "TEXT", "location": { "l": 45.36, "t": 93.84, "r": 225.84, "b": 80.88 }, "text": "Parent/Guardian Initials: ___", "reading_order": 22 } ] }, { "page": 2, "items": [ { "page": 2, "type": "TEXT", "location": { "l": 37.92, "t": 674.64, "r": 308.4, "b": 660.96 }, "text": "PARTICIPANTNAME:___", "reading_order": 0 }, { "page": 2, "type": "TITLE", "location": { "l": 38.16, "t": 648, "r": 325.68, "b": 633.6 }, "text": "MEDICATION 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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.", "reading_order": 8 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 40.32, "t": 374.64, "r": 194.4, "b": 362.4 }, "text": "This includes authorization for:", "list_id": "L3", "level": 0, "items": [ { "page": 2, "type": "LIST_ITEM", "location": { "l": 48, "t": 358.08, "r": 211.2, "b": 345.36 }, "text": "Emergency medical treatment", "marker": "•", "list_id": "L3", "level": 1, "reading_order": 0 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 48.24, "t": 341.52, "r": 136.8, "b": 328.8 }, "text": "Hospitalization", "marker": "•", "list_id": "L3", "level": 1, "reading_order": 1 } ], "reading_order": 9 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 41.76, "t": 327.36, "r": 430.8, "b": 295.2 }, "text": "Necessary medical procedures as determined by licensed medical personnel\nI understand that I am financially responsible for any medical services provided.", "marker": "•", "list_id": "L3", "level": 0, "reading_order": 10 }, { "page": 2, "type": "TEXT", "location": { "l": 40.08, "t": 275.52, "r": 139.2, "b": 263.04 }, "text": "□ I GIVE permission", "reading_order": 11 }, { "page": 2, "type": "TEXT", "location": { "l": 40.08, "t": 259.68, "r": 181.44, "b": 246.24 }, "text": "□ I DO NOT GIVE permission", "reading_order": 12 }, { "page": 2, "type": "TEXT", "location": { "l": 40.08, "t": 226.56, "r": 220.08, "b": 212.64 }, "text": "Parent/Guardian Initials: ___", "reading_order": 13 }, { "page": 2, "type": "TITLE", "location": { "l": 39.6, "t": 183.84, "r": 290.4, "b": 169.68 }, "text": "HEALTH INSURANCE ACKNOWLEDGEMENT", "reading_order": 14, "level": 2 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 39.36, "t": 164.4, "r": 555.12, "b": 134.88 }, "text": "I understand that Kentucky State University does not provide medical insurance coverage for participants. I agree that:", "list_id": "L4", "level": 0, "items": [ { "page": 2, "type": "LIST_ITEM", "location": { "l": 47.76, "t": 131.28, "r": 307.2, "b": 118.32 }, "text": "I am responsible for all medical expenses incurred", "marker": "-", "list_id": "L4", "level": 1, "reading_order": 0 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 48.24, "t": 115.2, "r": 356.64, "b": 101.52 }, "text": "I have provided current insurance information (if applicable)", "marker": "•", "list_id": "L4", "level": 1, "reading_order": 1 } ], "reading_order": 15 }, { "page": 2, "type": "TEXT", "location": { "l": 39.84, "t": 81.84, "r": 196.8, "b": 70.08 }, "text": "□ I ACKNOWLEDGE AND AGREE", "reading_order": 16 }, { "page": 2, "type": "TEXT", "location": { "l": 40.08, "t": 48.72, "r": 220.08, "b": 35.76 }, "text": "Parent/Guardian Initials: ___", "reading_order": 17 } ] }, { "page": 3, "items": [ { "page": 3, "type": "TEXT", "location": { "l": 45.36, "t": 649.44, "r": 315.6, "b": 636.96 }, "text": "PARTICIPANTNAME:___", "reading_order": 0 }, { "page": 3, "type": "TITLE", "location": { "l": 40.8, "t": 607.2, "r": 294.48, "b": 593.28 }, "text": "GENERAL PROGRAM ACKNOWLEDGEMENT", "reading_order": 1, "level": 2 }, { "page": 3, "type": "LIST_ITEM", "location": { "l": 41.52, "t": 587.52, "r": 140.64, "b": 574.56 }, "text": "I acknowledge that:", "list_id": "L5", "level": 0, "items": [ { "page": 3, "type": "LIST_ITEM", "location": { "l": 48.96, "t": 571.2, "r": 450.24, "b": 558 }, "text": "My child is expected to follow all camp rules, policies, and the Code of Conduct", "marker": "•", "list_id": "L5", "level": 1, "reading_order": 0 }, { "page": 3, "type": "LIST_ITEM", "location": { "l": 49.2, "t": 554.4, "r": 491.52, "b": 540.96 }, "text": "Failure to comply may result in disciplinary action, including dismissal from the program", "marker": "-", "list_id": "L5", "level": 1, "reading_order": 1 }, { "page": 3, "type": "LIST_ITEM", "location": { "l": 48.96, "t": 538.08, "r": 338.4, "b": 524.88 }, "text": "I have reviewed the program expectations with my child", "marker": "•", "list_id": "L5", "level": 1, "reading_order": 2 } ], "reading_order": 2 }, { "page": 3, "type": "TITLE", "location": { "l": 41.04, "t": 505.44, "r": 197.76, "b": 492.24 }, "text": "□ I ACKNOWLEDGE AND AGREE", "reading_order": 3, "level": 2 }, { "page": 3, "type": "TEXT", "location": { "l": 41.76, "t": 472.32, "r": 221.04, "b": 458.64 }, "text": "Parent/Guardian Initials: ___", "reading_order": 4 }, { "page": 3, "type": "TITLE", "location": { "l": 41.28, "t": 423.84, "r": 288.24, "b": 409.68 }, "text": "UNIVERSITY POLICY ACKNOWLEDGEMENT", "reading_order": 5, "level": 2 }, { "page": 3, "type": "LIST_ITEM", "location": { "l": 41.28, "t": 404.4, "r": 140.4, "b": 390.96 }, "text": "I acknowledge that:", "list_id": "L6", "level": 0, "items": [ { "page": 3, "type": "LIST_ITEM", "location": { "l": 48.72, "t": 387.84, "r": 450.24, "b": 374.64 }, "text": "My child is expected to follow all camp rules, policies, and the Code of Conduct", "marker": "•", "list_id": "L6", "level": 1, "reading_order": 0 }, { "page": 3, "type": "LIST_ITEM", "location": { "l": 48.72, "t": 371.28, "r": 491.52, "b": 357.84 }, "text": "Failure to comply may result in disciplinary action, including dismissal from the program", "marker": "-", "list_id": "L6", "level": 1, "reading_order": 1 }, { "page": 3, "type": "LIST_ITEM", "location": { "l": 48.72, "t": 354.48, "r": 338.16, "b": 341.04 }, "text": "I have reviewed the program expectations with my child", "marker": "•", "list_id": "L6", "level": 1, "reading_order": 2 } ], "reading_order": 6 }, { "page": 3, "type": "TITLE", "location": { "l": 41.04, "t": 322.08, "r": 197.52, "b": 309.12 }, "text": "□ I ACKNOWLEDGE AND AGREE", "reading_order": 7, "level": 2 }, { "page": 3, "type": "TEXT", "location": { "l": 41.76, "t": 288.72, "r": 221.04, "b": 275.04 }, "text": "Parent/Guardian Initials: ___", "reading_order": 8 }, { "page": 3, "type": "TITLE", "location": { "l": 45.36, "t": 221.28, "r": 271.92, "b": 207.12 }, "text": "SIGNATURES OF ACKNOWLEDGEMENT", "reading_order": 9, "level": 2 }, { "page": 3, "type": "TEXT", "location": { "l": 44.16, "t": 202.08, "r": 563.28, "b": 171.6 }, "text": "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.", "reading_order": 10 }, { "page": 3, "type": "TEXT", "location": { "l": 44.88, "t": 149.76, "r": 418.32, "b": 136.08 }, "text": "Parent/Guardian Signature: ___", "reading_order": 11 }, { "page": 3, "type": "TEXT", "location": { "l": 45.12, "t": 127.68, "r": 415.68, "b": 114.24 }, "text": "Printed Name: ___", "reading_order": 12 }, { "page": 3, "type": "TEXT", "location": { "l": 45.6, "t": 106.08, "r": 239.04, "b": 92.64 }, "text": "Date: _____", "reading_order": 13 }, { "page": 3, "type": "TEXT", "location": { "l": 172.08, "t": 47.76, "r": 436.56, "b": 35.28 }, "text": "Kentucky State University is an equal opportunity provider.", "reading_order": 14 } ] } ]