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# 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: ___