Please complete a separate health release for each child registered.

* = required

Student First Name:  *  
Middle Initial      
Student Last Name:  *  

Birth Date: * 

School Attended in May/June 2009: *  
Age as of June 1, 2009: *

Parent/Guardian First Name: *  
Parent/Guardian Middle Initial
Parent/Guardian Last Name: *  

Parent/Guardian Birthdate:  *  

RELEASE STATEMENT

I, *  , the undersigned, have read and agree to the following:

I understand the potential dangers and risks of participating in the LCSC Kids’ College program include, but are not limited to, death or serious injuries which may result in complete or partial impairment of my child’s body, general health and well being. In consideration of LCSC permitting me to associate my child with the program, I hereby voluntarily assume all risks associated with participation. To the extent permitted by law, I hereby agree to discharge and release the State of Idaho, Lewis-Clark State College, their administrators, directors, coordinators, employees, or their agents from and all liability, claims, causes of action or demands of any kind and nature whatsoever which may arise by or in connection with my child’s participation in any activities related to this LCSC program. The terms hereof shall serve as a release and assumption of risk for my child’s heirs, estate, executor, administrator, assignees, and all members of my family. My child is in good health. There is no medical reason why my child is not able to participate in this program. I hereby consent to first aid, emergency medical care and if necessary, admission to an accredited hospital when necessary for executing such care, for treatment for injuries that my child may sustain while participating in any activity associated with the program. I understand that it is my obligation to have a health and accident insurance policy in effect while my child is participating in this program or to otherwise be responsible for any and all medical expenses which may be incurred as a result of an accident while participating in the program; I also understand that I am responsible for all medical expenses not covered by my insurance. I certify that I am the parent or legal guardian of the named participant in this LCSC program.

I have read the above agreement. I assent to its terms and conditions. I acknowledge that my dependent and I have agreed to the terms and conditions, and I hereby give my consent to participation by my dependent in this program and to receive medical treatment as indicated, if necessary. I further agree to hold harmless the State of Idaho, Lewis-Clark State College, their administrators, directors, coordinators, employees, or their agents and all other parties referenced above/ as specified above.

I authorize the transport of my child, in an LCSC vehicle driven by a competent adult and covered by liability insurance, for any class that includes a field trip or class time off the LCSC campus.

HEALTH STATEMENT

Please list any and all physical conditions that LCSC program staff should know which may affect or be affected by participation in this program:


Present medical problems or conditions:*
(if none please enter N/A)
 

Medications taken regularly:* 
(if none please enter N/A)
 

Allergies (including allergies to medications):*
(if none please enter N/A) 
 

Limitations on physical activities:*
(if none please enter N/A)
 

Emergency Contact other than Parent/Guardian*  

Primary Phone: *    (Please include area code)

Secondary Phone: *   (Please include area code)
 

Name of Insurance Co.:           
(if none please enter N/A)

Name on Policy:           
(if none please enter N/A)



Address of Insurance Co.:

Phone of Insurance Co.:

Optional Media Release: *

  I authorize the use of my child's picture for media purposes

   I do not authorize the use of my child's picture for media purposes