KENTUCKY STATE UNIVERSITY Cooperative Extension Program 4-H Youth Development
PARENT/GUARDIAN AUTHORIZATION AND RELEASE
TO BE COMPLETED BY PROGRAM STAFF:
Program/Event Name: ___
Date: _____ 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 IF APPLICABLE
I give permission for my child to participate in all program 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: ___