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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: ___

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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: ___

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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: _____