Name: *

Name You Use (ex: Nickname, Chosen Name): *

Cell Phone (if permitted):

Age on the first date of the Program: *

Name: *

Cell Phone: *

Email: *

Name: *

Cell Phone: *

Name: *

Cell Phone: *

The minor child requires accommodations due to a disability. If yes, the Parent or Gurdian must inform (with sufficient notice) and cooperate with the Programming Team to determine if Reasonable Accommodations can be made. *
- Select Option Yes No

The minor child has other nutritional, physical, medical, social or emotional conditions or needs that staff should be aware of prior to participation in this Program. *
- Select Option Yes No

If yes, describe below *

As the parent/legal guardian of the minor child I authorize representatives of the University to obtain medical attention for my child in the event of an accident, serious illness, or medical emergency (as determined by University staff). I understand that medical attention may include, but may not be limited to: evaluation, transportation via ambulance or other conveyance, and/or treatment at GVSU’s Campus Health Center, an emergency room, or a hospital. I understand that I will be notified of the situation as soon as practicable, but that my child may receive treatment and/or be transported before I am able to be notified. I hold harmless and agree to indemnify the University from any claims, causes of action, damages and/or liabilities, arising out of or resulting from said medical treatment. I further agree to accept full responsibility for any and all expenses, including medical expenses that may derive from any injuries to my Child that may occur during his/her participation in the Activity. 

All Programs must establish a procedure for the pick-up and drop-off of Program Participants, specifying times and locations. The Authorized Adult(s) overseeing the drop-off and pick-up of Program Participants shall remain at the specified location until all minor children have been released. If a minor is not picked up, the Authorized Adult(s) will contact the parent or guardian, the Program Director, and finally, Grand Valley Department of Public Safety, if needed. 

The minor child has my express permission to travel to and from the Program independently and is therefore exempted from the drop-off and pick-up procedures developed by the Program. If yes, the minor child will be exempted from the drop-off and pick-up *
- Select Option Yes No

As the parent/legal guardian of the minor child, I certify that I have received, read, and understand the drop-off and pick-up procedures provided by the Program. And, I’ve indicated, here, whether the minor child has permission to be exempted from those processes. If the minor child is not exempted, and special arrangements need to be made, I understand that it is my obligation to inform the Program in a timely manner. I understand the escalation procedures if the minor child is not picked up in accordance with the pick-up procedures. 
 

All Programs, Program Directors, Authorized Adults, and Participants, including minor children and their parents/guardians are subject to standards outlined in GVSU’s University’s Policies, and (if applicable) Program-specific Conduct or Behavioral Expectations. 

As the parent/legal guardian of the minor child, I certify that GVSU’s University’s Policies, and (if applicable) Program-specific Conduct or Behavioral Expectations have been provided to me. I understand that Participation in the Program, including the minor child’s Participation, is subject to those standards. I also understand that if the minor child does not meet the prescribed standards of behavior, they may be asked to leave the Campus and/or Program immediately and may be expelled from the Program. I understand that I am not entitled to a refund if the minor child is expelled from the Program. 
 

Electronic signatures and electronically transmitted documents are binding.

As the parent/legal guardian of the minor child, I certify that the above information is the most up-to-date and correct to the best of my knowledge. I agree to the conditions noted herein as conditional to the minor child’s participation in GVSU Programs and related activities. I agree to release and agree to hold GVSU, its Board of Trustees, students, employees, and assigns harmless from all claims, actions, damages or liabilities for personal injury, damage, or illness relating to or arising out of any activity; except where the injury, damage or illness is caused by the gross negligence of the university’s employees. 

The minor child has my permission to participate in this Program.

Printed name of Parent/Guardian/Foster Parent *

Sign below:

Date *
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