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: ___