Breathe Youth Arts Program

Choose location child will attend:*

MadisonvilleBowling Green

Child's Name:*

First NameLast Name

Date of Birth:*

Date

Age:*

Gender:

Gender:*

Parent Guardian Name:*

First NameLast Name

Parent Guardian Phone Number:*

Area CodePhone Number

Parent Guardian Email*

example@example.com

Relationship to Student:*

Relationship to Student:

Please select all that apply for your child’s transportation needs. Check the appropriate boxes below:*

I request that my child be picked up from school and transported to the program.I request that my child be picked up from home and transported to the program.I request that my child be transported from the program to home.

School Name:*

Time your child is available for pick up from home:*

:HourMinutesAM/PM Option

Days needing transportation (Check all that apply):*

Mondays (Creative Writing)Tuesdays (Music, Dance, or Visuals Arts)Wednesdays (Culinary Arts)Thursdays (Music, Dance, or Visuals Arts)

Days needing transportation (Check all that apply):*

Mondays (Music, Dance, or Visuals Arts)Tuesdays (Culinary Arts)Wednesdays (Music, Dance, or Visuals Arts)

Emergency Contact Name:*

First NameLast Name

Emergency Phone Number:*

Area CodePhone Number

I, the undersigned parent/guardian, grant permission for my child, Student's Full Name , to be transported to Light of Chance, Inc. I understand and agree to the following:

I acknowledge that the program is not responsible for any unforeseen events, including but not limited to vehicle accidents, weather conditions, or delays caused by traffic.

2. Seat Belts and Safety: I understand that safety is a top priority, and my child will be required to wear seat belts or appropriate safety restraints at all times during transportation. Failure to comply with safety guidelines may result in my child being excluded from future transportation activities.

3. Medical Consent: In the event of a medical emergency, I authorize program staff to seek necessary medical treatment for my child, including but not limited to hospitalization, surgery, or anesthesia. I understand that every effort will be made to contact me or the emergency contact listed above before any medical decisions are made.

4. Insurance: I acknowledge that the youth program has liability insurance covering participants during program activities. I also understand that I am encouraged to maintain personal health insurance coverage for my child.

5. Behavior Expectations: I agree to inform my child of the behavior expectations during transportation. I understand that disruptive or unsafe behavior may result in my child being prohibited from future transportation activities.

6. Acknowledgment of Risks: I acknowledge that transportation inherently carries certain risks, including the possibility of accidents or injuries. I agree that neither the youth program nor its staff or volunteers shall be held liable for any injury or accident that may occur during transportation

Parent/ Guardian Signature

Today's Date*

Date

Please submit this form before the start of the transportation activities. Your child's safety is our top priority, and your cooperation in this matter is greatly appreciated.

If for some reason your child does NOT need to be picked up on a particular day, please contact us by e-mail at info@lightofchance.org or by phone at 270-875-4332.

Please verify that you are human*

Breathe Transportation Form

CHILD'S INFORMATION

PARENT/GUARDIAN INFORMATION

TRANSPORTATION OPTIONS

EMERGENCY CONTACT

RELEASE OF LIABILITY & TRANSPORTATION AGREEMENT