2014 Southeast KY Region Migrant Education

Summer Academy Checklist for Advocates Región de KY del sudeste para la Educación Migratoria

Lista de comprobación para la Academia de Verano para los Orientadores

Student Name / Nombre del Estudiante: _____________________________________________

County / Condado: ___________________________________________

Item Complete

Student Application / Permission Forms Complete / Aplicación del Estudiante / Complete esta planilla

Student App: ____ EKU Waiver: ____ Emergency Medical: ____ Media Release: ____ Movie Permission: _____

ILP Login Information / Información de Entrada al sistema de ILP User Name / Nombre del Usuario: ___________________________ Password / Clave: __________________________________

Desired Career / Carrera Deseada:

Parent Attendance at Closing Ceremony (June 20, 2014) Padres que asistirán al Cierre de la Ceremonia (Junio 20, 2014)

Num.de Asistencia:

T-shirt size / Tallas: XS S M L XL XXL XXXL

Student Achievement Levels / Niveles de Logro del Estudiante

Please list grade level for each subject area or level from last year’s state tests (or other standardized tests)

Por favor sólo indique el nivel de grado para cada especialidad o nivel de las pruebas de estado del año pasado (u otras pruebas estandarizadas)

Reading: ________ Lectura Math: ________ Matemática

EKU Challenge Course Release Forms Complete / EKU Curso de Desafio- forma de permiso completado

Get Air Lex: Participant Release Form Complete / Get Air Lex- forma de permiso para los participantes completado

SEKY REGION MIGRANT EDUCATION PROGRAM 2014 Summer Academy

REGIÓN D PROGRAMA DE EDUCACIÓN MIGRATORIO Academia de Verano de 2014

Application must be turned in with the following information by May 30, 2014. Se debe entregar la aplicación junto con la siguiente información para el 30 de mayo de 2014

_______ 1. Competed Application / Aplicación completa _______ 2. Parent and Student Signatures / Firma de los padres y estudiantes

Demographic Information/ Información demográfica: I. Student Section (to be completed by the appropriate person – student, advocate or parent/guardian) Name /Nombre: __________________________________________________________________ Preferred Name/Nombre preferido/apodo: ________________________________________ School/ Escuela: __________________________________________________ Address/: _________________________________ Phone Number/: ___________________ Domicilio Teléfono ___________________ Email address Correo electrónico /: ____________________________________________________ City / Ciudad / State / Edo / Zip Code / Cod Postal: ________________________________________ Birth date / Fecha de nacimiento: Month / Mes _________ Day / Día ________ Year / Año_________ Native Language / Idioma nativo __________ T-shirt Size: ____________ (tella de camiseta/franela) Academic Information / Información académico: Grade level / año de escuela (clase): ___7th Grade ___8th Grade ___9th Grade ___10th Grade ___11th Grade _____12th Grade (Next school year) Special interests / activities in which you have been involved in the last two years (in or out of school). Intereses especiales / actividades en que te hayas involucrado, dentro o fuera de la escuela ________________________________________________________________________________

Student Signature: _____________________________Date/Fecha: _____________________________

Staff: Have parent/guardian complete and sign the English or Spanish version of ALL authorizations

EMERGENCY MEDICAL RELEASE FORM / FORMA DE LIBERACIÓN MÉDICA DE EMERGENCIA

It is extremely important that this form be filled out accurately and in its entirety. The Region D Migrant Education Program Summer Academy staff must be aware of all medications that a student participant will be required to take during the Summer Academy. All participants should follow their physician’s orders for medications while attending camp. If you do not have health insurance, please be aware you (the parent or guardian) will be responsible for all health related expenses that may be incurred with any medical treatment deemed necessary while attending camp. / Es muy importante que esta forma sea llenada exactamente y en su totalidad. La Región D personal de Academia de Verano de Programa de Educación Migratorio debe ser consciente de todos los medicamentos que se requerirá que un participante del estudiante tome durante la Academia de Verano. Todos los participantes deberían seguir las órdenes de su médico por medicaciones asistiendo al campamento. Si usted no tiene seguro médico, por favor debe ser consciente usted (el padre o representante) será responsable de los gastos relacionados de toda la salud en que pueden incurrir con cualquier tratamiento médico juzgado necesario asistiendo al campo

Please print clearly and fill out ALL sections of this form.

Student Name: __________________________________________ Age: ____ Birth Date: ____________ Last/Apellido First/Nombre M.I./Inicial del 2do. Edad Fecha de Nacimiento Parent/Guardian Name: _______________________________________ Relationship: _____________ Nombre de los padres/representante Relación Address: ____________________________________________________________________________ Dirección (Street/Calle, Apt No / Num de Apartamento.) City/Ciudad Zip Code / Cod.Postal Home Phone / Teléfono: ____________________________ Telf. De trabajo: ________________________ Other Phone Contact (cell, neighbor): _____________________________________________________ Otro Num. de contacto (vecino, etc.)

Health Insurance Carrier ________________________________ Policy # _______________________ Portador de Seguro médico # de Póliza Student’s Doctor _______________________________ Doctor’s Phone: _______________________ Nombre del Dr. del Estudiante Teléf. Del Doctor Allergies (food, bee stings, contact, medicines): ____________________________________________ Alergias (Alimento, picaduras de abeja, medicinas) _________________________________________________________________________________ List all medication taking: _____________________________________________________________ Lista de medicamentos que está tomando What is the medication for: ____________________________________________________________ Para que es este tipo de medicamento Special Medical Needs (diabetic, ADHD, etc.): _____________________________________________ Necesidades médicas especiales (diabetes, ADHD, etc.)

Please list any specific instructions and information regarding medications or control of illness. (i.e. “must take medicine before a meal or must take injections first thing in the morning”.) _______________________________ __________________________________________________________________________________________

Please provide instructions and information / Por favor especifique las instrucciones en una lista de información

en cuanto a medicaciones o control de la enfermedad. (es decir “debe tomar la medicina antes de una comida o debe inyectarse a primera hora de la mañana”.)

Por favor proporcione instrucciones e información: ________________________________________________

Are there any physical changes or behavior that indicates an emergency that the staff should be aware of?/ ¿Hay allí algún cambio físico o el comportamiento que indica una urgencia de la cual el personal debería estar consciente?

Please give information on the best time and location to reach a parent/guardian (i.e. Between 8-12 and 1-5, I

can be reached at work; from 12-1, can be reached by my cell phone; and after 5, I will be at home.)/ Por favor infórmenos el mejor momento para llamarlos o localizarlos (Durante las 8-12 y 1-5, para poder llamarle al trabajo de 12-1, o puede ser localizado al celular después de las 5, o estaré en casa)

__________________________________________________________________________________ __________________________________________________________________________________ In the event of an EMERGENCY and the parent/guardian can not be reached, please give another emergency contact name and phone number below:/En caso de una EMERGENCIA y los padres/represent antes no puedan ser ubicados, por favor de dar otro numero de contacto __________________________________________________________________________________ Print Name/Nombre Relationship/Relación Phone Number/#deTeléfono __________________________________________________________________________________ In case of emergency, illness, or accident to _____________________________________________, In caso de emergencia, enfermedad o accidente Child’s Full Name / Nombre completo del Niño I give consent to the nearest appropriate medical facility to render medical emergency care deemed appropriate by the medical staff of the facility. Doy el consentimiento a la instalación médica apropiada más

cercana para dar el cuidado de emergencia médico juzgado apropiado por el personal médico de la instalación

Signature of Parent/Guardian: _________________________________________________________ Firma de los padres/representantes Effective Date: __________________________________ Fecha efectiva

CHALLENGE COURSE RELEASE FORM FORMA DE LIBERACIÓN DE CURSO DE DESAFÍO

Eastern Kentucky University Challenge Course

Participation Agreement Curso de Desafío de Eastern Kentucky University

Acuerdo de Participación

SEKY Migrant Education Summer Academy (2014) Print Participant Name / Imprima el Nombre Name of Group

Instructions: Please read this form carefully. Each participant or his/her parent/guardian must sign this Agreement before the program begins. Without all appropriate signatures, the individual may not be permitted to participate in the program.

I/My child desire(s) to participate in the Eastern Kentucky University Challenge Course, and I fully understand and appreciate the dangers, hazards, and risks inherent in the program, which dangers include but are not limited to serious or even mortal injuries and property damage./

I/My child understand(s) that participation in programs offered by the Eastern Kentucky University Challenge Course is based on the "Challenge by Choice" philosophy. I recognize that the program is designed to use experiential, engaging, teaching techniques, but that participation is purely voluntary. At all times I/my child will choose my/his/her level of participation in any activity. I/My child has completed the medical questionnaire on the back of this form and to my knowledge all information is accurate. I understand the employees of the EKU Challenge Course have received appropriate training and will work to protect the emotional and physical safety of myself/my child. I understand that climbing, high ropes courses, ground initiatives, and other activities in the Challenge Course which I/my child will participate in, entails certain risks. I recognize that there are certain dangers, risks, and possible injuries which are inherent in and may result from participation in the program. I understand that despite the safety precautions taken by EKU that it is impossible to guarantee that any participant will not be injured. I will, or have instructed my child to, obey all rules, regulations and instructions of program personnel in an effort to minimize such risks. I/My child is in good physical health and fitness such as to allow participation in the program. In the event of possible injury, I give permission for EKU to authorize the administration of emergency medical care to me/my child Therefore, for myself /my child, I knowingly and voluntarily assume all risks involved in my/my child’s participation, and do hereby release EKU and its Regents, officers, employees, and agents from any and all liability, damages, costs and expenses arising out of or relating to bodily or psychological injury, loss of life or personal property that may occur as a result of participating in this program. Instrucciones: Por favor lea esta forma cuidadosamente. Cada participante o sus padres deben firmar este acuerdo antes de comenzar el programa. Sin todas las firmas apropiadas, la persona no tiene permiso para particiar en el programa.

Yo/Mi hijo desea participar en los cursos de Desafío de Eastern Kentucky University y entiendo y estoy al tanto de los daño o peligros y riesgos inherentes en el programa, que los peligros incluyen, pero no son con heridas serias o hasta mortales y daño a la propiedad. Yo/Mi hijo, entendemos que la participación en programas ofrecidos por el Curso de Desafío de Eastern Kentucky University está basada en el Desafío por la filosofía Seleccionada. Reconozco que el programa es diseñado para usar empírico, contratación, enseñando técnicas, pero que la participación es puramente voluntaria. Mi hijo/a elegirá el nivel de él/ella en la participación en cualquier actividad Yo/ Mi hijo ha completado el cuestionario médico al dorso de esta forma y a mi conocimiento toda la información es exacta. Yo entiendo que los empleados del Curso de Desafío de EKU han recibido el apropiado entrenamiento y trabajaran para proteger tanto mental y física en la seguridad para mí o para mi hijo/a. Yo entiendo que al escalar, y usando las cuerdas es como parte del curso, iniciativas del suelo y otras actividades en el Curso de Desafío en los cuales para mí o mi hijo podrá participar en este programa. Entiendo que estoy al tanto de las precauciones y seguridad tomada por EKU que será imposible de garantizar de qué algún participante no se lastime. Yo o mi hijo estoy/está en Buena condición medica para que pueda participar. En caso de un accidente. Le doy permiso a EKU para que autorice a la administración del Centro de Emergencia les de todos los cuidados médicos necesarios. Por lo tanto, para mí / mi niño, a sabiendas y voluntariamente asumo todos los riesgos implicados en la participación de mi/mi niño, y libero realmente por este medio EKU y sus Regentes, oficiales, empleados, y agentes de alguno y toda la responsabilidad, daños, gastos y gastos provenientes o acerca de la herida corporal o psicológica, la pérdida de vida o propiedad personal que puede ocurrir a consecuencia de la participación en este programa.

Eastern Kentucky University Challenge Course Participation Agreement

Curso de Desafío de Eastern Kentucky University Acuerdo de Participació

I have read and understand and accept the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon the parties during the entire period of participation in the said program I grant EKU and persons acting through it, the rights to use, reproduce, assign, and/or distribute photographs, films, videotapes, and sound recordings of myself or my child for use in materials it may create. He leído y entiendo los términos y condiciones aclarados aquí y reconozco que este acuerdo debería ser efectivo y obligatorio por las partes durante el período entero de la participación en dicho programa

Concedo EKU y personas que actúan por ello, los derechos de usar, reproducir, adjudicar, y/o distribuir fotografías, películas, videocintas, y grabaciones sanas de mí o mi niño para el uso en materiales que esto puede crear. _____ Emergency Contact: __________________________ Signature of Participant’s Persona en caso de Emergencia Parent or Guardian REQUIRED La Firma del Padre/Representante es REQUERIDA Phone: Home: ______________________________ Business: _____________________________ Telefono: Casa Trabajo: _______ _______________________________________ Address Dirección _________ _______________ City State Zip Ciudad Edo. Cód. Postal

Eastern Kentucky University Challenge Course Participation Agreement

Curso de Desafío de Eastern Kentucky University Acuerdo de Participación

Medical Questionnaire / Cuestionario Médico

1. Are there any existing medical conditions that might effect your safe participation in this program? / Existe alguna

condición médica que pudiera afectar la seguridad en la participación en el programa.

___________________________________________________________________________________________________

2. Are you allergic to any of the following? Es alérgico a lo siguiente: Medication (e.g. penicillin, aspirin, etc.) __________________________ Medicina (Penicilina, aspirina, etc.) Insect bites (e.g. bee stings, etc.) _______________________________ Picada de insectos (Picadura de abeja, etc.) Other / Otro _____________________________________________________ If so, what is the nature of the reaction? __________________________________ Si es asi, cuál es la naturaleza de la reacción

EKU Challenge Course, 859-622-1217. http://www.ceo.eku.edu/challengecourse

Migrant Education Region D Summer Camp

Eastern Kentucky University

Permission for Movie Viewing

Based on a true story about a man named, Christopher Gardner. Gardner has invested heavily in a device

known as a “Bone Density Scanner.” He feels like he has made these devices. However, they do not sell as

they are marginally better than the current technology at a much higher price. As Gardner tries to figure out

how to sell them, his wife leaves him, he loses his house, his bank account, and credit cards. Forced to live

out in the streets with his son, Gardner is now desperate to find a steady job; he takes on a job as a

stockbroker, but before he can receive pay, he needs to go through 6 months of training, and to sell his

devices. – Written by John Wiggins

For additional Information, go to http://www.imdb.com/title/tt0454921/plotsummary, http://www.self-esteem-

school.com/the-pursuit-of-happiness.html, http://en.wikipedia.org/wiki/The_Pursuit_of_Happyness

----------------------------------------------------------------------------------------------------------------------

I give my permission for my child, ____________________________________ to view the movie, Pursuit of

Happyness, while attending Summer Camp. I understand that the movie is rated PG-13 for violent content,

thematic material, and language. I understand that the movie is being used for educational purposes. The

Migrant Education Summer Camp staff will lead discussions and monitor writing activities following the

movie. I also understand that the movie will not be viewed if all participants of the Migrant Education

Summer Camp do not have parent permission.

Parent/Guardian Signature: ____________________________________________ Date:

________________

Parent/Guardian Printed Name: __________________________________________

Programa para la Educación Migrante Campamento de Verano, Región D

Eastern Kentucky University

Permiso para ver una película

Historia basada en la vida real sobre un hombre llamado Christopher Gardner. Gardner ha invertido pesadamente en

un dispositivo conocido como 'un explorador de Densidad de Hueso'. Él siente que ha hecho estos dispositivos. Sin

embargo, éstos no se venden, cuando ellos son ligeramente mejores que la tecnología corriente en un precio mucho más

alto. Cuando Gardner trata de entender cómo venderlos, su esposa lo abandona, él pierde su casa, su cuenta bancaria, y

tarjetas de crédito. Obligado a vivir en las calles con su hijo, Gardner está muy desesperado ahora por encontrar un

trabajo estable; él toma un trabajo como un corredor de bolsa, pero antes de que él pueda recibir su sueldo, él tiene que

pasar por 6 meses de entrenamiento, y vender sus dispositivos. Escrita por John Wiggins

Para más información, visite http://www.imdb.com/title/tt0454921/plotsummary, http://www.self-esteem-school.com/the-pursuit-of-happiness.html, http://en.wikipedia.org/wiki/The_Pursuit_of_Happyness

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Doy permiso a mi hijo/a, ____________________________________ para que vea la película, Coach Carter, mientras atienda

el Campamento de Verano. Entiendo que la película es calificada PG-13 por contenido violento, material temático, y lenguaje.

Entiendo que la película está siendo usada para objetivos educativos. El personal del Campamento de Verano de Educación

Migratorio conducirá discusiones y será monitoreado y hará que los participantes escriban, discutan y hagan unas actividades

después de película. También entiendo que la película no será vista si todos los participantes del Campo de Verano de

Educación Migratorio no tienen el permiso de los padres/representantes.

Firma de Padres/Representante: ____________________________________________ Fecha: ________________

Nombre impreso de los Padres /Representantes: __________________________________________

Eastern Kentucky University Waiver of Liability, Assumption of Risk, and Indemnity Agreement

THIS IS A LEGALLY BINDING RELEASE, WAIVER, INDEMNIFICATION OF LIABILITY, AND EXPRESS ASSUMPTION OF RISK.

Please read it carefully, fill in all blanks and initial each paragraph before signing.

_____ I, _____________________________, hereby affirm that I have read this document in its entirety. By my signature below and by my

initialing each paragraph, I agree to each and every term and condition of this document.

_____ I UNDERSTAND THAT PARTICIPATION IN 2014 Southeastern Kentucky Migrant Education Summer Academy (hereafter

referred to as “Event”), which involves

EKU Challenge Course: Teamwork, Communication & Confidence Workshop EKU Campus

Galaxy Bowling: Recreational & Social Event Richmond, KY

Keeneland: Educational Field Trip Lexington, KY

Bluegrass Community Technical College College & Career Readiness Lexington, KY

Get Air Lex. Recreational & Social Event Lexington, KY

CARRIES WITH IT CERTAIN INHERENT RISKS AND DANGERS. THESE RISKS INCLUDE, BUT ARE NOT LIMITED TO:

PERSONAL DAMAGE, INJURY, PARALYSIS, LOSS, DEATH, OR PROPERTY DAMAGE OR LOSS. I understand that these risks are

described by way of example only, and that there are numerous other risks inherent in this activity to which I may be exposed. In the event of

possible injury, I give permission for EKU to authorize the administration of medical care.

_____ IN CONSIDERATION OF BEING PERMITTED TO PARTICIPATE IN ANY WAY IN the events listed above in Richmond, KY and

Lexington, KY, June 16-20, 2014 on behalf of my myself and anyone claiming interest through me, DO HEREBY INTENTIONALLY,

KNOWINGLY, AND VOLUNTARILY RELEASE, WAIVE, DISCHARGE, INDEMNIFY, AND AGREE TO HOLD HARMLESS

EASTERN KENTUCKY UNIVERSITY, and all its employees, regents, and volunteers FROM ANY AND ALL CLAIMS, ACTIONS,

SUITS, PROCEDURES, COSTS, EXPENSES, DAMAGES, AND LIABILITIES brought as a result of my involvement in this event, whether

such damage, injury, or loss results from NEGLIGENCE or some other cause, and to reimburse them for any such expenses incurred.

_____ I understand that the University in no way represents, or acts as an agent for, any third party trip organizer, the transportation carriers,

hotels, and other suppliers of service during this event. I understand and agree that the University is not responsible for losses or expenses due

to sickness, weather, strikes, hostilities, wars, natural disasters, or other such causes or disruptions. Further, the University is not responsible for

any disruption of travel arrangements, or any consequent additional expenses that may be incurred therefrom.

If event is off-campus, check one of the following concerning transportation:

_____My child has permission to travel with the University’s Group. I fully understand and appreciate the dangers, hazards, and risks

inherent in the transportation to, from, and during this event, which dangers include, but are not limited to serious or even mortal

injuries and property damage.

_____My child does not have permission to use the University provided transportation.

_____ I HEREBY ASSERT THAT MY CHILD’S PARTICIPATION IS VOLUNTARY AND THAT I KNOWINGLY ASSUME ALL SUCH

RISKS. I understand that I signed this document as my own free act and deed; no oral representations, statements, or inducements, apart from

the foregoing written statement, have been made.

____ I further agree that this document will be interpreted in accordance with the laws of the Commonwealth of Kentucky. If any term or

provision of this document shall be held illegal, unenforceable, or in conflict with any law governing this document, the validity of the

remaining portions shall not be affected.

Student Information

First Name: _____________________________________________ Last Name: _______________________________________________

Phone Number: __________________________________________ E-mail Address: ____________________________________________

______________________________________________________________________________________/______/______________________

Parent/Guardian’s Signature DATE

___________________________________________________________________________________________________________________

Print name

Eastern Kentucky University Renuncia voluntaria de Responsabilidad, Asunción de Riesgo, y Acuerdo de Indemnidad

ESTE ES UNA LIBERACIÓN LEGAL, RENUNCIA VOLUNTARIA, LA INDEMNIZACIÓN DE RESPONSABILIDAD, Y ASUNCIÓN EXPRESA DEL RIESGO. Por favor léalo con cuidado, rellene todos los impresos y escriba sus iniciales en cada párrafo antes de la firma.

_____Yo, _____________________________, por este medio afirmo que he leído este documento en su totalidad. Por mi firma abajo y por el que firmo con las iniciales en cada párrafo, estoy de acuerdo con todo y cada término y condición de este documento. _____ ENTIENDO QUE EN LA PARTICIPACIÓN en la Academia de Verano de Educación migrante del Sudeste de Kentucky 2014 (a continuación referido como "Acontecimiento"), que implica Curso de Desafío de EKU: Trabajo en equipo, Comunicación y Taller de Confianza Campus de EKU Galaxy Bowling / Boliche: Acontecimiento Recreacional y Social Richmond, KY Keeneland: Paseo Educativo Lexington, KY Comunidad de Bluegrass Preparación de Carrera y Colegio de Colegio Técnica Lexington, KY Get Air Lex. : Eventos recreacionales y Sociales, Lexington, KY LLEVA CON ELLO CIERTOS RIESGOS INHERENTES Y PELIGROS. ESTOS RIESGOS INCLUYEN, PERO NO SON LIMITADOS con: DAÑO PERSONAL, HERIDA, PARÁLISIS, PÉRDIDA, MUERTE, O DAÑO A LA PROPIEDAD O PÉRDIDA. Entiendo que estos riesgos son descritos por vía del ejemplo sólo, y que hay numerosos otros riesgos inherentes en esta actividad a la cual puedo ser expuesto. En caso de la herida posible, doy el permiso para EKU para autorizar la administración de asistencia médica. _____ EN CONSIDERACIÓN A SER PERMITIDO PARTICIPAR DE CUALQUIER MODO EN los acontecimientos puestos arriba mencionados en Richmond, KY y Lexington, KY, el 16-20 de junio de 2014 de parte mí y alguien reclamando el interés por mí, HACEN POR ESTE MEDIO INTENCIONADAMENTE, A SABIENDAS, Y VOLUNTARIAMENTE LIBERAN, RENUNCIAN, DESCARGAN, INDEMNIZAN, Y CONSIENTEN EN SOSTENER UNIVERSIDAD DE KENTUCKY DEL ESTE INOCUA, y todos sus empleados, regentes, y voluntarios de ALGUNO Y TODAS LAS RECLAMACIONES, ACCIONES, PLEITOS, PROCEDIMIENTOS, GASTOS, GASTOS, DAÑOS, Y RESPONSABILIDADES traídas a consecuencia de mi participación en este acontecimiento, si tal daño, herida, o pérdida resultan de la NEGLIGENCIA o alguna otra causa, y reembolsarlos por algún tal gasto incurrido. _____ Entiendo que la Universidad de ninguna manera representa, o actúa como un agente para, cualquier organizador de viaje de tercero, los portadores de transporte, hoteles, y otros proveedores del servicio durante este acontecimiento. Entiendo y estoy de acuerdo que la Universidad no es responsable de pérdidas o gastos debidos a enfermedad, tiempo, huelgas, hostilidades, guerras, desastres naturales, u otras tales causas o interrupciones. Adelante, la Universidad no es responsable de ninguna interrupción de arreglos de viajes, o ningún gasto adicional consiguiente en que pueden incurrir de allí. Si el acontecimiento es fuera de campus, compruebe uno de lo siguiente acerca del transporte: _____ Mi niño tiene el permiso de viajar con el Grupo de la Universidad. Totalmente entiendo y aprecio los peligros, riesgos, y riesgos inherentes en el transporte a, de, y durante este acontecimiento, que los peligros incluyen, pero no son limitados con heridas serias o hasta mortales y daño a la propiedad. _____ Mi niño no tiene el permiso de usar el transporte proporcionado de la Universidad. _____ POR ESTE MEDIO AFIRMO QUE LA PARTICIPACIÓN DE MI NIÑO ES VOLUNTARIA Y QUE A SABIENDAS ASUMO TODOS TALES RIESGOS. Entiendo que firmé este documento como mi propio acto libre y hecho; ningunas representaciones orales, declaraciones, o incentivos, aparte de la declaración escrita anterior, han sido hechos. ____ Estoy de acuerdo que este documento será interpretado de acuerdo con las leyes de la Commonwealth de Kentucky. Si algún término o la provisión de este documento serán sostenidos ilegales, inaplicables, o en el conflicto con alguna ley que gobierna este documento, la validez de las porciones restantes no será afectada. Información de Estudiante Nombre:________________________________________________ Apellido:______________________________________ Num.de Telefono:_______________________________ Dirección de email:__________________________________________ _____________________________________________________ ___________________ Firma de padres o representantes Fecha __________________________________________________________________________ Nombre imprento

PHOTOGRAPHIC CONSENT AND RELEASE FORM

I hereby authorize Eastern Kentucky University and its employees, regents, and volunteers (hereafter referred to as “University”) to:

(a) Record my likeness and voice on a video, audio, photographic, digital, electronic or any other medium; and

(b) Use my name in connection with these recordings; and

(c) Use, reproduce, exhibit or distribute in any medium (e.g., print publications, video tapes, CD-ROM, Internet/WWW) these recordings for any purpose that the University deems appropriate, including promotional or advertising efforts.

I release the University from liability for any violation of any personal or proprietary right I may have in connection with such use. I understand that all such recordings, in whatever medium, shall remain the property of the University. I have read and fully understand the terms of this release. NAME: ______________________________________________________ ADDRESS: ______________________________________________________ Street

______________________________________________________

City State Zip PHONE: ______________________________________________________ PARENT’s SIGNATURE: _________________________________________________ DATE: __________________________________________________

CONSENTIMIENTO PARA LAS FOTOGRAFIAS/VIDEOS

Yo autorizo a Eastern Kentucky University y a sus empleados y sus voluntarios (que tengan que ver con el campamento de verano de la Universidad) para: Grabe mi imagen y voz en un vídeo, de audio, fotográfico, digital, electrónico o cualquier otro medio; y (a) Usar mi nombre en relación a estas grabaciones; y (b) Uso, reproduzca, exponga o distribuya en cualquier medio (ejemplo, imprima publicaciones, videocintas, CD-ROM, Internet/WWW) estas grabaciones para cualquier objetivo que la Universidad juzga apropiado, incluso esfuerzos promocionales o publicitarios. Libero la Universidad de la responsabilidad de cualquier violación de cualquier derecho personal o patentado que puedo tener en relación a tal uso. Entiendo que todas tales grabaciones, en cualquier medio, permanecerán la propiedad de la Universidad. He leído y totalmente entiendo los términos de esta liberación. NOMBRE: ______________________________________________________ DIRECCION: ______________________________________________________ Calle

______________________________________________________

Ciudad Estado Código postal Teléfono: ______________________________________________________ Firma de los padres: _________________________________________________ FECHA: __________________________________________________

Get Air Lexington

Parents/Guardians:

Name (First & Last):

Birthdate (mm-dd-

yyyy):

Child's Name

(First & Last):

Birthdate (mm-dd-

yyyy):

Child's Name

(First & Last):

Birthdate (mm-dd-

yyyy):

Child's Name

(First & Last):

Birthdate (mm-dd-

yyyy):

Child's Name

(First & Last):

Birthdate (mm-dd-

yyyy):

Address:

Zip Code:

City:

State:

Phone Number:

Email:

PARTICIPATION AGREEMENT

THIS PARTICIPATION AGREEMENT is made and effective as of the last date executed (hereinafter the "Effective Date") by and between

Get Air Lex, LLC. (hereinafter "Get Air") and the adult or guardian identified (hereinafter "Adult"), who is executing this Participation

Agreement personally and in behalf of themselves and any minor children specified (the adult and children are collectively referred to

hereinafter as the "Participants"). Get Air and Participants are collectively referred to hereinafter as the "Parties."

WITNESSETH

WHEREAS, Get Air owns and/or operates a recreational trampoline park located at 400 E. Brannon Road., Nicholasville, KY 40356

(hereinafter the "Trampoline Park"); and

WHEREAS, Get Air makes the Trampoline Park available to customers solely for recreational use and enjoyment, not as a service to the

general public; and

WHEREAS, Participants desire to participate in the recreational activities available at the Trampoline Park; and

WHEREAS, Participants know, understand and acknowledge that participation in the recreational activities available at the Trampoline Park is

purely voluntary, not essential or necessary, and intended solely for recreational enjoyment; and

WHEREAS, Participants know, understand and acknowledge that the use of trampoline equipment (including the trampoline equipment at

Trampoline Park) constitutes an inherently risky recreational activity that may result in serious injury (such as paralysis and death), damage to

property, and injury to third parties; and

WHEREAS, Get Air will not make the Trampoline Park available to Participants unless Participants are willing to take personal responsibility

for any and all injuries to Participants, damage to property, and injuries to third parties that may result from Participants' voluntary participation

in the recreational activities available at the Trampoline Park and any of the other causes identified hereinafter.

AGREEMENT

NOW THEREFORE, in consideration of the premises and the mutual covenants, conditions, representations, and agreements contained herein,

as well as the cost of admission to the Trampoline Park, the Parties hereby agree as follows:

1. Waiver and Release of Liability

Participants, on behalf of themselves, and their parents, spouses, children/wards, heirs, assigns, representatives, estates, successors, attorneys,

insurers, and all other persons, firms, partnerships or corporations connected therewith (collectively referred to hereinafter as the "Releasing

Parties"), forever, finally, fully, permanently and unconditionally waive, release, acquit and discharge Get Air, and its present and former

employees, owners, members, principals, directors, subsidiaries, affiliates, representatives, predecessors, successors, shareholders, partners,

parents, officers, agents, assigns, servants, attorneys, insurers, suppliers, manufacturers, clients, customers, participants, and all other persons,

firms, partnerships or corporations connected therewith (collectively referred to hereinafter as the "Released Parties"), to the fullest extent

permitted by law, from any and all charges, claims, debts, disputes, demands, suits, causes of action, rights of action, dues, sums of money,

accounts, liabilities, losses, expenses and damages, absolute or contingent, known or unknown, whether or not asserted, threatened, alleged or

litigated, now existing or arising in the future, at law or equity, whether caused by the negligence of Released Parties or otherwise, that arise

out of or relate in any way to Participants' use of the trampoline equipment and any of the other facilities at the Trampoline Park, and any

claims for costs, expenses and attorneys' fees associated therewith.

2. Indemnification

Releasing Parties hereby indemnify and covenant to hold harmless and defend Released Parties from any and all charges, claims, debts,

disputes, demands, suits, causes of action, rights of action, dues, sums of money, accounts, liabilities, losses, expenses and damages, absolute

or contingent, known or unknown, whether or not asserted, threatened, alleged or litigated, now existing or arising in the future, at law or

equity, whether caused by the negligence of Released Parties or otherwise, that arise out of or relate in any way to Participants' use of the

trampoline equipment and any of the other facilities at the Trampoline Park, and any claims for costs, expenses and attorneys' fees associated

therewith.

3. Covenant Not to Sue

Releasing Parties hereby covenant not to sue Released parties on account of any and all charges, claims, debts, disputes, demands, suits, causes

of action, rights of action, dues, sums of money, accounts, liabilities, losses, expenses and damages, absolute or contingent, known or

unknown, whether or not asserted, threatened, alleged or litigated, now existing or arising in the future, at law or equity, whether caused by the

negligence of Released Parties or otherwise, that arise out of or relate in any way to Participants' use of the trampoline equipment and any of

the other facilities at the Trampoline Park, and any claims for costs, expenses and attorneys' fees associated therewith.

4. Assumption of Risk

Releasing Parties know, understand and acknowledge that the use of trampoline equipment (including the trampoline equipment at Trampoline

Park) constitutes an inherently risky recreational activity that may result in serious injury (such as paralysis and death), damage to property, and

injury to third parties. Releasing Parties know, understand and acknowledge that these risks include, but are not limited to, falling off

equipment, double bouncing, collision with fixed objects and/or people, and failed attempted jumps and stunts. Releasing Parties hereby

assume the risk of personal injury or death, damage to property, and injury to third parties that arise out of or relate in any way to Participants'

past, present or future use of the trampoline equipment and any of the other facilities at the Trampoline Park

5. Representations, Warranties, and Further Assurances

Adult represents and warrants that she/he was given ample opportunity to read and review this Participation Agreement. Adult further

represents and warrants that she/he is the parent or legal guardian of the minor Participants, and that she/he has and will maintain adequate

medical or other insurance to cover and pay for any possible injury that may occur to Participants and/or third parties that arise out of or relate

in any way to Participants' use of the trampoline equipment and any of the other facilities at the Trampoline Park. Participants further represent

and warrant that they will read and follow the rules of the Trampoline Park, and will cause other Participants (including minor children) to

follow such rules, including without limitation the rules posted on signs within the Trampoline Park.

6. Integration

This Participation Agreement constitutes the entire and only agreement and understanding between the Parties with respect to the subject

matter hereof and may not be altered, enlarged, or abridged except by an agreement in writing executed by all of the Parties hereto.

7. Binding Nature of this Participation Agreement

The provisions of this Participation Agreement shall inure to the benefit of, and be binding upon, the Parties hereto and their respective

successors and assigns.

8. Severability

All the provisions of this Participation Agreement shall be considered as separate terms and conditions. In the event that any provision hereof is

determined to be invalid, prohibited, or unenforceable by a court or other body of competent jurisdiction, this Participation Agreement shall be

construed as if such invalid, prohibited, or unenforceable provision had been more narrowly drawn so as not to be invalid, prohibited, or

unenforceable. Notwithstanding the foregoing two sentences, in the event that any of the provisions of this Participation Agreement should be

determined to be invalid, prohibited or unenforceable, the validity, legality and enforceability of the remaining provisions contained in this

Participation Agreement shall not in any way be affected or impaired thereby.

9. Choice of Law and Jurisdiction

This Participation Agreement shall be governed by and construed in accordance with the laws of the State of California without regard to any

conflict of law rules of another state. Releasing Parties explicitly acknowledge and understand that the laws of the State of California may be

more likely to recognize the validity and enforceability of the terms of this Participation Agreement-and particularly the parental waiver and

indemnification provisions-than the laws of the other states (including the state where the Trampoline Park is located and/or the Releasing

Parties reside). In executing this Participation Agreement, Releasing Parties' expressly intend and desire for the substantive laws of the State of

California to govern the validity and enforceability of this Participation Agreement.

10. Mediation and Arbitration

Any and all disputes, claims, or controversies arising out of or relating in any way to Participants' use of the trampoline equipment and any of

the other facilities at the Trampoline Park shall be submitted to a formal mediation using a mediator either appointed by the American

Arbitration Association or any other mediator to which the Parties agree. Mediation must commence within any applicable statute of

limitations, and shall be deemed to commence when a Party notifies the agreed-upon mediator, in writing, of its request for mediation, the

subject of the dispute, and the relief requested. Mediation shall be deemed to be in the nature of settlement negotiations and any dispute not

otherwise satisfactorily resolved shall be subject to mandatory, final and binding arbitration. Either Party may initiate arbitration with respect to

the matters submitted to mediation by notifying the other Parties, in writing and within ten days after the mediation is concluded, of its demand

for arbitration. Unless otherwise agreed by the Parties, the mediator shall be disqualified from serving as arbitrator in the case. Any mediation

and arbitration shall be conducted in California. Arbitration shall be the sole and exclusive forum for resolution of the dispute, claim or

controversy, and the award shall be in writing, state the reasons for the award, and be final and binding. Judgment thereon may then be entered

in any court of competent jurisdiction.

The Agreement also Gives Get Air the rights and permissions to the all media captured on the Trampoline Park premises, Including but not

limited to all security footage, photos, and video for any and all purposes including publication on both printed and electronic media and on the

Internet.

11. Attorney Fees for Breach of this Participation Agreement

In the event either Party hereto defaults in any of the covenants or agreements contained herein, including the tenth clause, the defaulting Party

shall pay all costs and expenses, including reasonable attorneys' fees, incurred by the other Party.

IN WITNESS WHEREOF, the Adult has signed this Participation Agreement as of the dates set forth.

I, ______________________, have read and agree to the terms and conditions set forth in the preceding waiver as

shown for both myself and for any dependents or youth I have specified. I give my permission for Migrant Staff to

complete the online application for my children listed below.

Student(s) Name: __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________

Parent’s Signature: __________________________________________________

Date: ______________________