[ { "page": 1, "items": [ { "page": 1, "type": "TITLE", "location": { "l": 177.6, "t": 760.56, "r": 482.16, "b": 705.36 }, "text": "KENTUCKY STATE UNIVERSITY\nCooperative Extension Program 4-H Youth Development\nRESIDENTIAL SUMMER CAMP RELEASE OF LIABILITY", "reading_order": 0, "level": 1 }, { "page": 1, "type": "TITLE", "location": { "l": 23.76, "t": 679.68, "r": 193.2, "b": 668.4 }, "text": "TO BE COMPLETED BY PROGRAM STAFF:", "reading_order": 1, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 24, "t": 659.52, "r": 567.12, "b": 647.28 }, "text": "Program/Event Name: ___", "reading_order": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 24.96, "t": 640.8, "r": 264.72, "b": 628.56 }, "text": "Date(s):___", "reading_order": 3 }, { "page": 1, "type": "TEXT", "location": { "l": 24.96, "t": 640.8, "r": 566.88, "b": 628.56 }, "text": "County/Location: ___", "reading_order": 4 }, { "page": 1, "type": "TEXT", "location": { "l": 25.68, "t": 622.56, "r": 570.96, "b": 609.36 }, "text": "Employee Name: ___", "reading_order": 5 }, { "page": 1, "type": "TEXT", "location": { "l": 325.44, "t": 622.56, "r": 570.72, "b": 609.84 }, "text": "Program Area: ___", "reading_order": 6 }, { "page": 1, "type": "TITLE", "location": { "l": 25.68, "t": 586.8, "r": 145.2, "b": 574.8 }, "text": "Participant Information", "reading_order": 7, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 25.44, "t": 570, "r": 579.84, "b": 558.48 }, "text": "Participant Name: ___ Date of Birth: ___", "reading_order": 8 }, { "page": 1, "type": "TEXT", "location": { "l": 25.68, "t": 548.4, "r": 421.92, "b": 536.64 }, "text": "Parent/Guardian Name: ___", "reading_order": 9 }, { "page": 1, "type": "TEXT", "location": { "l": 20.16, "t": 527.52, "r": 281.04, "b": 515.52 }, "text": "Telephone:_____", "reading_order": 10 }, { "page": 1, "type": "TEXT", "location": { "l": 25.68, "t": 527.52, "r": 564, "b": 515.28 }, "text": "Email: ___", "reading_order": 11 }, { "page": 1, "type": "TITLE", "location": { "l": 22.56, "t": 491.52, "r": 151.44, "b": 477.84 }, "text": "RELEASE OF LIABILITY", "reading_order": 12, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 22.56, "t": 467.52, "r": 547.68, "b": 428.64 }, "text": "In exchange for the above-named youth participating in 4-H Summer Camp programs and activities on the campus of Kentucky State University, including field trips and use of KSU facilities and services, the undersigned agrees to the following:", "reading_order": 13 }, { "page": 1, "type": "TITLE", "location": { "l": 31.92, "t": 410.4, "r": 247.92, "b": 397.92 }, "text": "1. CODE OF CONDUCT AND INSTRUCTIONS", "reading_order": 14, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 31.44, "t": 395.52, "r": 555.84, "b": 353.76 }, "text": "I agree that my child will observe and obey all camp rules, Code of Conduct expectations, and guidelines, and further agree that my child will follow oral instructions or directions given by Kentucky State University employees, representatives, agents, volunteers, and camp staff.", "reading_order": 15 }, { "page": 1, "type": "TITLE", "location": { "l": 32.16, "t": 330, "r": 157.68, "b": 318.48 }, "text": "2. ASSUMPTION OF RISK", "reading_order": 16, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 39.6, "t": 314.16, "r": 523.68, "b": 288.24 }, "text": "I understand that there are inherent risks associated with participation in camp activities, including travel, recreational activities, outdoor activities, use of facilities, and interaction with other participants.", "reading_order": 17 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 39.84, "t": 285.6, "r": 556.08, "b": 260.16 }, "text": "I knowingly and voluntarily permit my child to participate with full understanding that such activities may involve risks of personal injury, illness, property damage, or other unforeseen circumstances.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 18 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 39.84, "t": 258.48, "r": 510.96, "b": 246 }, "text": "I voluntarily assume responsibility for risks that may arise as a result of participation in camp activities.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 19 }, { "page": 1, "type": "TITLE", "location": { "l": 35.52, "t": 221.76, "r": 207.12, "b": 209.76 }, "text": "3. RELEASE AND HOLD HARMLESS", "reading_order": 20, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 34.56, "t": 206.64, "r": 552.72, "b": 165.36 }, "text": "I release and discharge Kentucky State University, its Board of Regents, employees, representatives, agents, and volunteers from claims, liabilities, damages, losses, or expenses arising out of participation in camp activities or use of university facilities, except where caused by gross negligence or intentional misconduct.", "reading_order": 21 }, { "page": 1, "type": "TITLE", "location": { "l": 35.52, "t": 141.84, "r": 144, "b": 130.32 }, "text": "4. INDEMNIFICATION", "reading_order": 22, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 34.8, "t": 126.96, "r": 541.68, "b": 85.44 }, "text": "I agree to indemnify and hold harmless Kentucky State University against claims, causes of action, damages, judgments, costs, or expenses, including attorney fees and litigation costs, arising from my child's participation in camp activities or presence on university property.", "reading_order": 23 }, { "page": 1, "type": "TEXT", "location": { "l": 44.64, "t": 46.56, "r": 353.76, "b": 33.84 }, "text": "Parent/Guardian Signature ___\nDate ___", "reading_order": 24 }, { "page": 1, "type": "TEXT", "location": { "l": 393.12, "t": 46.32, "r": 517.92, "b": 33.84 }, "text": "Date", "reading_order": 25 } ] }, { "page": 2, "items": [ { "page": 2, "type": "TEXT", "location": { "l": 36.24, "t": 684, "r": 405.36, "b": 671.04 }, "text": "NAME OF CAMP/PROGRAM:___", "reading_order": 0 }, { "page": 2, "type": "TEXT", "location": { "l": 36.24, "t": 665.28, "r": 338.88, "b": 652.56 }, "text": "PARTICIPANT NAME:___", "reading_order": 1 }, { "page": 2, "type": "TITLE", "location": { "l": 35.28, "t": 631.68, "r": 150.96, "b": 619.92 }, "text": "5. PROPERTY DAMAGE", "reading_order": 2, "level": 2 }, { "page": 2, "type": "TEXT", "location": { "l": 34.8, "t": 616.8, "r": 556.56, "b": 589.68 }, "text": "I agree to be financially responsible for damages to Kentucky State University property caused by negligent, reckless, or intentional acts of my child.", "reading_order": 3 }, { "page": 2, "type": "TITLE", "location": { "l": 35.28, "t": 569.28, "r": 138.24, "b": 557.28 }, "text": "6. GOVERNING LAW", "reading_order": 4, "level": 2 }, { "page": 2, "type": "TEXT", "location": { "l": 34.56, "t": 554.16, "r": 529.68, "b": 527.28 }, "text": "I understand that any legal claim arising from participation in the program shall be governed by the laws of the Commonwealth of Kentucky.", "reading_order": 5 }, { "page": 2, "type": "TITLE", "location": { "l": 36.24, "t": 489.36, "r": 142.56, "b": 476.88 }, "text": "ACKNOWLEDGMENT", "reading_order": 6, "level": 2 }, { "page": 2, "type": "TEXT", "location": { "l": 55.68, "t": 466.32, "r": 121.92, "b": 454.32 }, "text": "I certify that:", "reading_order": 7 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 63.12, "t": 451.92, "r": 353.04, "b": 439.2 }, "text": "I am the parent/legal guardian of the participant listed above;", "marker": "•", "list_id": "L2", "level": 0, "reading_order": 8 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 64.08, "t": 436.8, "r": 205.44, "b": 425.52 }, "text": "I am at least 18 years of age;", "marker": "-", "list_id": "L2", "level": 0, "reading_order": 9 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 63.6, "t": 423.12, "r": 424.08, "b": 410.88 }, "text": "I have read and understand this Residential Summer Camp Release of Liability;", "marker": "•", "list_id": "L2", "level": 0, "reading_order": 10 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 63.84, "t": 408.48, "r": 233.76, "b": 396.96 }, "text": "and I voluntarily agree to its terms.", "marker": "•", "list_id": "L2", "level": 0, "reading_order": 11 }, { "page": 2, "type": "TEXT", "location": { "l": 40.32, "t": 335.52, "r": 349.68, "b": 322.32 }, "text": "Parent/Guardian Signature ___", "reading_order": 12 }, { "page": 2, "type": "TEXT", "location": { "l": 41.52, "t": 295.92, "r": 165.6, "b": 283.92 }, "text": "Date _____", "reading_order": 13 } ] } ]