Parental Release Form

Student Name *
Student Name
Home Address *
Home Address
Workshop Date *
Workshop Date
Legal Guardian *
Legal Guardian
Legal Guardian (home/cell) *
Legal Guardian (home/cell)
Legal Guardian (work) *
Legal Guardian (work)
Emergency Contact *
Emergency Contact
Emergency Contact (home/cell) *
Emergency Contact (home/cell)
Emergency Contact (work) *
Emergency Contact (work)
In the event of serious accident or injury, every effort will be made to contact a parent or guardian. Because I understand that a situation could arise when emergency treatment may be necessary and I cannot be reached, I hereby authorize Read and Write Kalamazoo personnel to make provisions for treatment with the appropriate medical personnel or facility.
Policy Holder *
Policy Holder
Birthdate *
Birthdate
Please inform us of any allergies or health concerns (including any and all medications) which may be pertinent to our time with your student.
Photo Release *
I permit Read and Write Kalamazoo to take photographs of my student for the explicit purpose of chronicling and promoting the RAWK program. I understand that any photographs of my child taken during RAWK programming will not be used by anyone not affiliated with Read and Write Kalamazoo.
RAWK involves working in large and small groups, on-on-one interactions, giving and receiving feedback, reading aloud, and active listening. Is there any information you can give us that will help us support your student in these activities?