N:\CEWD-Division\Youth_Program\3_Forms\Forms for PARENTS\Parent Contact Forms
LF 8/21/2018
Class Name Student's Date of Birth Student's Gender
Male
Students Name Student's Age Student's Grade
Student's Address
Parent / Guardian's Name
City, State & Zip Code Main Phone Alternative Phone
County Email
Student's School
Student's School District
Pr
imary Emergency Contact Name Secondary Emergency Contact Name
Phone Phone
Parent / Guardian's Name (Print)
Parent / Guardian's Signature Date
*Email this completed form to: lcc.edu/seriousfun BEFORE class starts.
Medical Information
Female
Alternative Emergency Contacts
Contact and Release Form – LCC Youth Program
In the event I cannot be reached and my child becomes ill, or for some other reason must be sent home, please call one of the authorized adults named
below. I understand the same individuals will be contacted if my child is not picked up promptly at the end of his/her Youth Programs class and I am unable to
be reached.
(Note: Include ALL names of people picking up your child on the Parent Contact and Release Form (siblings, grandparents, carpool drivers, etc.)
Please indicate medical information about your child that may affect their participation in the Youth Program. Attach an additional sheet if necessary.
None Medical Information/Allergies (please describe below):
Release and Liability
___(Initial) Photo Release (Optional): I authorize Lansing Community College to use still photographs, motion pictures, video tapes, digital images, and/or sounded recordings of
my child without restriction of any sort. I understand the pictures or sound may be edited and combined with other pictures and sound recordings. The final edited pictures and sounds
may be shown without restriction, including radio and television broadcast, cablecast, printed publication, Internet web pages, and any other media including CD, DVD, digital imaging,
and network streaming. Lansing Community College may assign these rights to other parties for their use. (Please check the box at the left to include the “Photo Release” in your
approvals per your signature below).
___(Initial) Student Code of Conduct (Required): All students must follow the LCC Student Code of Conduct located at:
https://internal.lcc.edu/catalog/policies_procedures/studentrulesguidelines.aspx
___ (Initial) Medical Release (Required): I authorize the staff of Lansing Community College and its Youth Program staff to act on my behalf according to their best judgment in
any emergency that requires securing medical attention for my child and I waive and release the College and its Youth Program staff from all liability for any injuries or illnesses incurred
while participating in the School program.
___ (Initial) Release of Liability (Required): I am the parent/guardian of the student applying to participate in Lansing Community College’s Youth program. I understand that
this program may include sporting or other activities that present some risk of injury to the participants. I assume all risks of, and I fully release Lansing Community College, its affiliates,
officers, board members, employees, representatives, suppliers and others involved in providing services in connection with the Youth program, from any and all liability arising from
events or activities conducted as part of the Program.
___ (Initial) Tuition Waiver (Required only for LCC Employees using Dependent Tuition Waiver Benefits): I am the parent/guardian of a student attending Youth program and
using my earned and unused tuition waiver benefits for the tuition amount of Youth classes. It is my responsibility to make sure that tuition waiver benefits are available for my
dependents and that the cost of classes does not exceed the available earned benefit total. By initialing this paragraph, I fully understand that any deficit for cost of tuition, not covered
by available earned tuition waiver, is my personal responsibility and I am required to pay any outstanding amount immediately. I also understand that any required paperwork for
dependent benefits have been submitted and accepted through the Human Resource division of LCC. Any deficit balance for Youth Program tuition not covered by tuition waiver
benefits may be subject to review and action through LCC Financial Services Division.
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