2020 GOVERNOR’S SCHOLARS PROGRAM PARENTGUARDIAN PERMIT AND WAIVER

1 G 01 GOVERNOR’S OFFICE (UPDATED AUGUST 2021)
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2020 GOVERNOR’S SCHOLARS PROGRAM PARENTGUARDIAN PERMIT AND WAIVER
2021 GOVERNOR’S SCHOLARS PROGRAM FACULTY APPLICATION PLEASE TYPE OR
ATTACHMENT D EXECUTIVE ORDER 0101200460 GOVERNOR’S WORKFORCE INVESTMENT BOARD

Parent Guardian Permit and Waiver


2020 Governor’s Scholars Program

Parent/Guardian Permit and Waiver


This provides parent/guardian permission for medical examination and treatment in an approved and authorized hospital, physician’s office, or other medical facility.


The following consent form should be signed by the parent or legal guardian of the student, so that appropriate diagnosis and treatment may be carried out, and so that no unnecessary delays will occur with emergency procedures, including operational procedures. No operations will be performed, except in an emergency, without parent or legal guardian’s being contacted and fully informed.


I give my permission for _______________________________________ to receive necessary medical treatment at an authorized hospital, medical facility, or office by appropriate medical professionals.



In addition, the Governor’s Scholars Program, Inc. (“GSP”) cannot guarantee that you or your Scholar will not become infected with COVID-19. Further, attending the GSP could increase your risk and your Scholar’s risk of contracting COVID-19.


By signing this agreement and in consideration of the benefits of an in-person program for my Scholar, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk of exposure and costs that my Scholar and I may be exposed to, in relation to participating in programs held by the GSP and that such exposure or infection may result in personal injury, illness, permanent disability, death, damage, loss, and will hold harmless and indemnify the GSP, their employees, agents, directors, representatives from any claim, liability, or expense of any kind, including legal costs and professional/attorney fees.


The undersigned acknowledges the GSP is a voluntary program and that my Scholar’s name will be released, with our permission, to Kentucky’s colleges and universities for the purpose of recruitment, enrollment and scholarships, regardless of in-person attendance.



Parent/Legal Guardian Signature: ____________________________________


Relationship to Student_____________________________________________


Date:_________________


Scholar Signature: _________________________________________________


Date:_________________





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