Permission to Leave, Medical Information and Refund Policy Agreement

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During the summer months, KYAC provides on-site supervision for our participants. We are considered a drop-in program. Participants are free to come and go as they please unless boundaries are explicitly written and approved by their parent/guardian. The KYAC staff will monitor your child in accordance with your preferences. Please clearly state whether or not you grant permission for your child to independently leave the site.

Child's Name *

Please Check One *

Yes, my child is allowed to leave the KYAC site alone

Yes, my child is allowed to leave the KYAC site only with a staff member

No, my child is not allowed to leave the KYAC site alone

Additional conditions or comments

Please indicate any medical conditions or allergies that our staff should be aware of:

In order to receive a refund, notice must be given to a KYAC staff in person, by phone or email at least 24 hours before departure. This allows us reasonable time to find another participant to attend and fill our booking. By signing this document I am aware of this policy and my child is aware of their restrictions to leave the KYAC site. I am also aware that my child must arrive at the site at least 10 minutes before field trip departure with a water bottle. If your child fails to be onsite 10 minutes prior to departure or is unable to meet field trip requirements (ie: closed toed shoes, water, lunch, etc) then KYAC staff reserves the right to hold them back and no refund will be issued. Type name below. *

Parent/Guardian Phone Number *

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