KAYN Student 2017-2018 Permission, Transportation, Media & Medical Release Form
Parent/ Guardian Name: *
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Student Name: *
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Grade/ Age: *
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Address: *
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Phone: *
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It is okay to Text me at this number:
Email: *
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Emergency Contact: *
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Emergency Phone: *
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Please list any known foods, contact type and/or medications the Student is allergic to: *
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Please list any known medical conditions and/or limitations the student has: *
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As a parent or legal guardian of the above named student, I give permission for the above named student to attend and participate in KAYN events throughout the 2017-2018 school year. *
Required
As a parent or legal guardian of the above named student, I understand that KAYN carries no medical or hospitalization coverage for participants in activities, ministries, services or events sponsored by KAYN. Furthermore, I will not hold KAYN’s staff, volunteers, or agents liable for any accident that the above named student may incur while traveling to/from or attending activities, gatherings or events sponsored by KAYN. In the instance(s) that the above named student becomes injured/ill while at a KAYN sponsored activity or event, I hereby authorize the staff, volunteers, and agents of KAYN to use their judgment in providing first aid, medical assistance, and/or care, and/or to secure medical aid and ambulance service transportation to a medical facility for further treatment and care. To the best of my knowledge, the above named student has no medical, physical, emotional, mental or other condition that would make it inadvisable for full participation. (Please note any information pertinent to caring for your child in the area provided above.) *
Required
Additionally, as a parent or legal guardian of the above named student I give permission that the approved staff or volunteers of KAYN can transport the child named to and from any KAYN events and meetings. *
Required
Furthermore I acknowledge that on occasion, KAYN takes photographs or makes audio/visual recordings of students involved in sponsored activities. Such media may be published to the public through our digital or printed media. I consent to the use of such audio/visual. *
Required
Finally, I understand that this form is effective from the date signed until September 1st of 2018, or until revoked in writing by the signee. *
Required
Electronic Signature of Parent/Guardian *
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