USD 259 Middle School After School Program Permission Form

Please sign and complete the form below

STUDENT INFORMATION
Grade (select one)
Gender (select one)
Ethnicity (choose one)
Race (choose one)
Number of people in the household
(include all household residents and total income from all sources):
(include all household residents and total income from all sources)
(include all household residents and total income from all sources)
(include all household residents and total income from all sources)
(include all household residents and total income from all sources)
(include all household residents and total income from all sources)
(include all household residents and total income from all sources)
(include all household residents and total income from all sources)
Parent/Guardian's Signature
(Please sign in the space below the agreed terms)

I/we the undersigned, parent(s)/guardian(s) having legal custody/legal guardianship of said minor, give permission to attend any of the Middle School After-School Program activities.  The said minor is physically able and mentally prepared to participate in all activities as described for said program. I/we hereby voluntarily and knowingly assume all risks and dangers inherent and incidental to the activities for which I/we have given my/our permission and thereby will not hold the Wichita YMCA & Wichita Public Schools liable for any injuries incurred during these activities.
  1. I/we do hereby grant permission for the said minor to be transported by a properly insured vehicle as required by (Kansas Law KSA 40-3107e) to and from the activities associated with the Middle School After-School Program.
  2. I/we do hereby grant permission for photos of my/our child to be used by the Wichita YMCA & Wichita Public Schools for promotional and educational purposes.
  3. I/we do hereby grant permission for student surveys to be given to my/our child pertaining the Wichita YMCA & Wichita Public Schools.
My signature below certifies that the information I have provided above is true and accurate under penalty of perjury.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.