8/14/2019 KIPP Through College 2009-2010 Informed Consent Forms-High School

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CONSENT TO RELEASE OF EDUCATION RECORDS AND OTHER CONFIDENTIALINFORMATION(High School)

I, Parent/Guardian of ___________________ hereby request __(See school name below)___ to listKIPP NYC through College (KTC) as a secondary parent contact throughout the duration of highschool for my Child and authorize the School to release educational records and other confidentialinformation to KTC.

I authorize the School named below to release the following information to KTCas requested by KTC staff members:

Copies of all parent information including report cards, progress reports, teachercomments, newsletters, etc

Copies of all financial statements including monthly invoices, registration/general fees,scholarships, and financial aid

Any and all confidential information requested by KTC and all other materials, written,requested or required relating to the student named above.

In addition, I authorize the School named below to allow KTC staff members to meet with my child onschool premises.

I also authorize KTC Staff to speak directly with teachers or administrators at the School namedbelow and authorize teachers and administrators at the School to discuss my child freely and frankly

with KIPP staff members.

I understand KIPPs request for my consent is to aid in High School and College Advisement.

I understand that my consent is voluntary and may be revoked at anytime.

I hereby release ___(See school name below)____, its officers and employees, of and from anyliability to me/us arising from or related to the provision of such reports, materials, or information.

Students High School Name: _______________________________

_______________________________Signature of Parent/Guardian

8/14/2019 KIPP Through College 2009-2010 Informed Consent Forms-High School

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KIPPNYCTHROUGHCOLLEGECONSENTANDRELEASEFORMACTIVITY/TRIPNAME:KIPPNYCthroughCollege(KTC)DESCRIPTION/LOCATION/METHODOFTRANSPORTATION: AfterschoolandweekendactivitiesrunbyKTCstaff,whichtakeplaceataKIPPNYCmiddleschool. Studentsareresponsiblefortheirowntransportation.Onoccasion,KTCmay

providesubway

passes

for

students

in

need.

DATES:From7thgradethroughthestudents18thBirthdayI,________________________,amtheparentorlegalguardianoftheminorchild/childrenlistedbelow.Igivemypermissionformy

child/childrentoparticipateintheactivityortriplistedabove.IunderstandthatparticipationinKTCincludesphysicaleducationas

wellasclassroomactivitiesandoffsitetrips.(Fortrips:Ihavereadtheinformationprovided,ifany,aboutthetripidentifiedabove.)

ACKNOWLEDGEMENTOFRISKSANDASSUMPTIONOFRISKANDRESPONSIBILITY(Wheneverthewordchildisusedinthisform,thetermreferstoallofthechildrenidentifiedatthebottom.Iunderstandthatin

signingthisTripandActivityConsentandReleaseFormIamconsentingtotheparticipationintripsandoractivitiesforallofthe

childrennamedabove.IfIamastudentovertheageof18,Iamsigningthisformonmyownbehalf.)

ACKNOWLEDGMENTOFRISKS:Irecognizethefactthattherearerisks,foreseeableandunforeseeable,intheactivitiesdescribedaboveandinalltripsandalltravelrelatedactivities.Irealizethatmychildcouldsufferdeathorinjuryorillnessandrequiremedical

attention.Iacknowledgetheserisksandconfirmthatmychildsparticipationinthisactivityortripisvoluntary.Iconsenttomy

childsparticipationinthistripandallactivitiesexceptforthefollowing_________________________________________________.

EXPRESSASSUMPTIONOFRISKANDRESPONSIBILITY:MychildsparticipationintheabovenamedactivityortripisvoluntaryandIassumeallrisksandfullresponsibility,onbehalfofallpartiesincludingmyself,mychild,mychildsotherguardians,andmychilds

heirsandassigns,for(a)anyandalllossesincurredasadirectorindirectresultofpersonalinjury,accident,illness,ordeath,and(b)

anyandalldamagetoorlossofpersonalpropertyarisingoutof,relatingto,orinconnectionwithanytheabovenamedactivitiesor

tripsoranytriprelatedactivity.

WAIVERANDRELEASEFROMLIABILITY:Onbehalfofmychild,myself,mychildsotherguardiansandmychildsheirsandassigns,Ihereby

assume

all

risks

and

waive,

release,

and

forever

discharge

KIPP

and

its

trustees,

employees,

agents

and

its

related

entities

fromanyandallliability,actions,anddamagesofwhateverkind,including,withoutlimitation,general,special,compensatoryand

punitivedamages,forpersonalinjury,propertydamage,negligenceorwrongfuldeatharisingoutof,relatingto,oroccasioned

whollyorinpartbytheactivityortriporanytriprelatedactivities.

MEDICALAUTHORIZATION:Iherebyauthorizeanymedicaltreatmentdeemednecessarywhilemychildisparticipatinginanyactivitiesreferredtoabove.Intheeventofillnessorinjury,IauthorizeKIPPandeachofitsemployees,representativesandagents

totakesuchmeasuresasareavailableandappropriateinthejudgmentofthepersonstakingsuchmeasures,andIconsentto

emergencymedicaltreatmentandcarewhichmaybedeemednecessarytoberendered.KIPPwillmakereasonableeffortstoreach

meintheeventofanemergencyrequiringmedicalcare.

IHAVEREADTHISAGREEMENTANDUNDERSTANDITSCONTENTS.IASSUMETHEAFOREMENTIONEDRISKS,ANDAGREETOTHE

WAIVEROF

LIABILITY

AND

TO

HOLD

KIPP

HARMLESS

Student_______________________________________________________________________________

SignatureofParent/Guardian,Student(ifover18) Date

(PrintName) EmergencyTelephone

8/14/2019 KIPP Through College 2009-2010 Informed Consent Forms-High School

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RELEASE FORM FOR MEDIA RECORDING(Alumni under Age 18)

I, ________________________________________, do hereby agree that KIPP NYC throughCollege (KTC), its staff and agents, have the right to take photographs, videotape or digital recordings

of my child(ren) ___(See names below)___, as they participate in the KTC Program.

I do hereby release to KTC, its staff and agents all rights to exhibit photos, videotape or digitalrecordings which may include images or sound recordings of my child(ren) in print and electronicform. I understand that these materials may be used at the discretion of KTC for purposes relating toits educational mission, including, but not limited to, explaining and promoting its program,development and funding, recruitment and staff training. I understand that my child(ren) may berecognizable in these materials, but will not be personally identified by name without my expresspermission.

I understand that neither I nor my child(ren) will receive financial or other remuneration for use of

his/her/their images in photographs, videotape or digital recordings which are shown in any form ofmedia pursuant to this agreement.

This Agreement is effective with respect to the children listed below until they have reached their 18thbirthday. Children who have reached their 18th birthday will be asked to consent to this release ontheir own behalf.

Minor Child #1 _____________________________________ KIPP School ________________(PRINT NAME)

Minor Child #2_____________________________________ KIPP School ________________(PRINT NAME)

Minor Child #3_____________________________________ KIPP School ________________(PRINT NAME)

Parent/ Guardian Signature: __________________________________ Date: _____________