N:\CEWD-Division\Youth_Program\C_Forms\Parent Contact Forms\Parent_Contact_Form_Fillable.docx
Revised 1/5/2018
**Please bring this form with you on the first day of class.**
Contact and Release Form – LCC Youth Program
Class Name
Student’s Name
Student’s Age
Student’s Grade
☐Male
(Check one)
☐Female
Student’s Address
Parent / Guardian’s Name
City, State, Zip Code
Main Phone
Alternative Phone
County
Email
Student’s School
Student’s District
Alternative Emergency Contacts
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.)
Primary Emergency Contact Name
Secondary Emergency Contact Name
Phone
Phone
Medical Information
Please indicate medical information about your child that may affect their participation in the Youth Program. Attach an additional sheet if necessary.
☐
☐
Medical Information/Allergies (please describe below):
___(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) 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.
Parent / Guardian’s Name (print)
Parent / Guardian’s Signature
Date
