TKC Release Form – Boys and Girls Club – Starkville PLEASE COMPLETE ALL SECTIONS AND SIGN BELOW Participant's InformationParticipant's Name(Required) First Last Participant's Grade(Required)Participant's Gender(Required)MaleFemaleParent/Guardian InformationParent/Guardian Name(Required) First Last Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Parent/Guardian Email Address(Required) Parent/Guardian Phone Number(Required)EMERGENCY AUTHORIZATIONEmergency Contact OTHER THAN Parent(Required)Phone(Required)Does your child have any allergies or require any special medication?(Required) Yes No If yes, please explain:(Required)Authorization(Required) I (Parent/Guardian) give permission for emergency medical treatment of my child for illness or accident if I cannot first be contacted. PHOTO/VIDEO RELEASEPhoto/Video Authorization(Required) There is nothing more encouraging than seeing children having a great time learning about God! Occasionally, TAG Kids’ Club may photograph or video club activities to share the work of the Club. I hereby assign and grant to TAG Kids’ Club, its subsidiaries, and successors, and assign the unqualified right to the ownership, use and proceeds of all photographs or video of me or my minor child, without reservation or limitation, including use of photographs or video of me or my minor child for advertising and promotional purposes. PERMISSION TO PARTICIPATE & EMERGENCY RELEASE HOLD HARMLESS STATEMENTParticipation Permission / Emergency Release Hold Harmless Statement(Required) My child has my permission to participate in the program sponsored by TAG Kids’ Club. I hereby agree that TAG Kids’ Club, TKC certified teacher, team leaders, its community service partners, partner agencies, directors, officers, agents, employees, successors, designees, representatives, affiliates, and volunteers (‘The TAG Kids’ Club Parties’) shall not be liable for any injury, accident or loss which my child may sustain while participating in activities of any kind whether sponsored by or under the supervision of TAG Kids’ Club. I further agree to indemnify and to hold harmless TAG Kids’ Club, its team leaders, certified teachers, volunteers or designates of any kind from any claim whatsoever. Parent or Guardian Signature(Required)Your NameYour NameYour NameYour NameParent Full NameDate(Required) TAG Kids’ Club is a privately sponsored program and is not endorsed or sponsored by any school district. This program is made available on the same terms and conditions as other privately sponsored programs with activities of interest to children and parents. Visit us at www.tagkidsclub.com.
