CPE Minor Authorization & Waiver CPE Minor Authorization & Waiver Step 1 of 4 - Minor 0% Minor's InformationMinor's Name* First Last Date of Birth*mm/dd/yyyy MM slash DD slash YYYY Age* Gender* Male Female Emergency ContactsThe parents/guardian listed below will be the only ones notified in the event of an emergency.Parent/Guardian Name* First Last Parent/Guardian Phone Number*Parent's phone number. This is also the main emergency contact number.Parent/Guardian Email Address* Parent/Guardian Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Name* First Last Emergency Contact Phone Number*Relationship to Child* Backup Emergency Contact Name First Last Backup Emergency Contact PhoneBackup Relationship to Child Authorized for PickupPlease list any individual other than yourself who is authorized to pick up your child (participant). Authorized individuals must be at least 16 years of age, must pick up the Participant in person, and may be requested to show identification to program staff. The Participant will not be permitted to leave the program with anyone who is not listed below or who does not provide acceptable identification upon request.Pickup Name 1* First Last Pickup Phone 1*Pickup 1 Relationship to Child* Pickup Name 2* First Last Pickup Phone 2*Pickup 2 Relationship to Child* Pickup Name 3 First Last Pickup Phone 3Pickup 3 Relationship to Child Authorized DismissalAuthorized Dismissal (FOR CHILDREN 16 OR OLDER)*If your child is at least 16 years of age and will be responsible for his/her own transportation to and from the Program, and may sign himself/herself out at the end of the Program. Yes No Medical Information & Authorization for Medical CareMedical InformationMedical information we need to know about Participant (current conditions, physical limitations, past injuries, etc.)AllergiesAllergies (medications, stings, foods, iodine, latex, etc.)MedicationsMedications Participant is currently taking, dosage, and times taken. KSU faculty, staff and volunteers are not equipped to administer medications to Participants. All participants should be able to administer their own medications.Date of last Tetanus shot MM slash DD slash YYYY AccommodationsDoes your child need any accommodations to safely participate in this program? Yes No Please explain special accommodationsHealth Insurance Information (if available)Note: Kennesaw State University does not offer any form of health, liability, or other types of insurance for participants. If available, please attach a copy of the front and back of your insurance card with this form.Health Insurance Provider Health Insurance PhonePolicy Number Physician/Pediatrician Practice Physician Phone NumberAuthorization for Medical Treatment I consent to medical and/or surgical care as may become necessary for the Participant’s well-being, should the need arise, and I understand that I will be solely responsible for the cost. I authorize Kennesaw State University to communicate in emergencies with the person(s) identified in my submission materials. I hold harmless and agree to indemnify Kennesaw State University from any claims, causes of action, damages, and/or liabilities arising out of or resulting from said medical treatment. By signing this form, I agree that all information is accurate and current, that all important information is listed on this form, and to the best of my knowledge, my child is capable of participating safely in the Program. I acknowledge that my failure to disclose relevant information may result in harm to my child and/or others during this program. I agree to notify the program of any changes in the above information as soon as possible. Required Authorization* I have read, understand and agree to the terms above Waiver and Release for MinorsPARENT OR GUARDIAN, PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING: LIABILITY WAIVER, RELEASE, INDEMNITY AND PROMISE NOT TO SUE: I, the undersigned below, in consideration of my child’s or ward’s participation in the Event(s) referenced above and any related activities thereto including training, preparation, and travel separately and collectively, the “Event”), wherever the/these Event(s) may occur, acknowledge that I am aware that as a result of my child’s or ward’s participation in the Event, there exists the potential for injuries including but not limited to scrapes, bruises, broken bones, and various injuries to the body, and I freely assume on my child’s or ward’s behalf all risks incidental to such participation. In consideration of my child’s or ward’s participation in the Event and in my child’s or ward’s behalf, and on behalf of my child’s or ward’s heirs, executors, administrators and next of kin, I hereby release, covenant not to sue, and forever discharge the Released Parties (as defined below) of and from all liabilities, claims, actions, damages, costs and expenses of any nature arising out of, related to, or in any way connected with my child’s or ward’s participation in the Event and/or any such related and associated activities, and further agree to indemnify and hold each of the Released Parties harmless from and against any and all such liabilities, claims, actions, damages, costs and expenses including by way of example, but not limited to, all attorneys’ fees, costs of court, and the costs and expenses of other professionals and disbursements up through and including any appeal. This agreement to indemnify shall extend to any claim filed by my child or ward upon reaching the age of majority. I, for my child and/or ward, understand that this Release and indemnity includes any claims based on the negligence, action or inaction of any of the Released Parties and covers bodily injury (including, without limitation, death), property damage, and loss by theft or otherwise, whether suffered by me or my child or ward either before, during or after such participation. I declare that my child or ward are physically fit and have the skill level required to participate in the Event and/or any such related and associated activities. I further authorize medical treatment for my child or ward, at my cost, if the need arises. For the purposes hereof, the “Released Parties” are: Kennesaw State University, the Board of Regents of the University System of Georgia, all Event sponsors, and each of their respective parent, subsidiary, affiliated or related companies; and the officers, directors, employees, agents, representatives, successors, assigns and volunteers of each of the foregoing entities. I also acknowledge that persons employed by Kennesaw State University may take photographs and/or videos of my child’s or ward’s participation and allow the use of these materials on behalf of the University without limitation or compensation including the release of my and/or my child’s or ward’s name. I also agree that during the time my child or ward is involved with the Event, he or she will be bound by all rules, regulations, policies, procedures and guidelines of Kennesaw State University and the Board of Regents. This Waiver and Release Form shall be governed by the laws of the State of Georgia, and any legal action related to or arising out of this Waiver and Release Form shall be commenced exclusively in the Superior Court in and for Cobb County, Georgia. I understand that the acceptance of this liability waiver, release, indemnity and promise not to sue Kennesaw State University or the Board of Regents of the University System of Georgia or any agent or employees thereof, shall not constitute a waiver, in whole or in part, of sovereign or official immunity by said Board, its members, officers, agents and employees. I certify I am eighteen (18) years of age or older and, if I am executing this Waiver and Permission Form on behalf of my child or ward, the information set forth above pertaining to my child or ward is true and complete. I HAVE READ, UNDERSTOOD AND ACCEPT THE CONDITIONS OF THIS LIABILITY RELEASE, INDEMNITY, AND PROMISE NOT TO SUE.Required Authorization* I have read, understand and agree to the terms above Participant Code of ConductThe Program has established rules and standards of conduct for all Participants. It is the responsibility of the Parent/Legal Guardian and the Participant to review the Program rules and standards of conduct. If applicable, dismissed Participants are not eligible for a refund of any fees or expenses. The Parent/Legal Guardian is responsible for all costs associated with removing the Participant from the Program due to his/her misconduct, including but not limited to transportation costs to return the Participant home. PARTICIPANT AGREEMENT I understand that as a condition for participating in the Program I must comply with the Program’s rules and standards of conduct and follow all reasonable direction of the Program Staff. Failure to comply with the Program’s rules and standards of conduct or failure to comply with the reasonable direction of Program Staff may result in my being dismissed from the Program.Code of Conduct Acknowledgement My child and I have read, understand and agree to the above code of conduct PARENT/LEGAL GUARDIAN AGREEMENT I understand that my child will be subject to the rules and standards of conduct of the Program and Kennesaw State University. I further understand that my child’s violation of the rules and standards of conduct or failure to comply with the reasonable direction of Program Staff may result in my child’s dismissal from the Program. I accept responsibility for all costs associated with removing my child from the Program, including but not limited to transportation costs to return the Participant home. I understand that dismissed Participants are not eligible for a refund of any fees or expenses. Code of Conduct Acknowledgement I have read, understand and agree to the above code of conduct Photography Authorization I acknowledge persons employed by Kennesaw State University may take photographs and/or videos of the participant named above and allow the use of these materials on behalf of the University without limitation or compensation.Photography Authorization* Yes No SignatureYou will be required to sign these documents at our registration desk when you first drop off your child for one of our programs, or, when you submit the form, you will be able to download and print the form so you can sign it and bring it to us with your child on the first day of the program.CAPTCHA
